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CANCER 
RELIEF OF PAIN AND POSSIBLE CURE 



THE MACMILLAN COMPANY 

NEW YORK • BOSTON • CHICAGO 
ATLANTA • SAN FRANCISCO 

MACMILLAN & CO., Limited 

LONDON • BOMBAY • CALCUTTA 
MELBOURNE 

THE MACMILLAN CO. OF CANADA, Ltd. 

TORONTO 



CANCER 



RELIEF OF PAIN AND POSSIBLE 
CURE 



BY 
SKENE KEITH, M.B, F.R.C.S.Ed. 

AUTHOR OF "INTRODUCTION TO THE TREATMENT OF DISEASE BY 

GALVANISM," "ELECTRICITY IN THE TREATMENT OF UTERINE 

TUMOURS," "GYNAECOLOGICAL OPERATIONS" 

AND 

GEORGE E. KEITH, M.B., CM. 

AUTHOR OF "TEXT-BOOK OF ABDOMINAL SURGERY" 
WITH MR. SKENE KEITH 



THE MACMILLAN COMPANY 

1908 

All rights reserved 






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! i WO GopJci- H 

J APR 

4 

COPY a 



Copyright, 1908, 
By THE MACMILLAN COMPANY. 



Set up and electrotyped. Published April, 1908. 



Norfooot! $regs 

J. 8. Cushlng Co. — Berwick & Smith Co. 

Norwood, Mass., U.S.A. 



®0 

THE GENERAL PRACTITIONERS 
OF THE UNITED KINGDOM 

FROM WHOM 

WE HAVE RECEIVED MUCH HELP 

THIS LITTLE BOOK 

IS DEDICATED 



PREFACE 

We give the following pages as a contribution 
to the treatment of the most difficult subject in 
medicine or surgery, not as a finished work. 
They comprise the result of nearly five years of 
experiment conducted on the same lines ; and 
as we have in addition fifteen years of experi- 
ment in other directions, we know many of the 
difficulties the experimenter has to face. We 
have tried to keep to facts and have entered 
into no theories, though originally we did try 
to work from them. To avoid being too dis- 
cursive we have not given all the cases we have 
treated, but have included all which appeared 
to give any information. The treatment is not 
suitable for all cases of cancer, and we hope that 
others will help us to discover which are the 
cases it is likely to cure and which should be 
attacked in some other way. 



viii PREFACE 

Practically all have been treated by ourselves 
or by Miss Gertrude Keith, L.R.C.P., etc., 
who, from her position as late Medical Officer 
to the Church Army Dispensary, was able to 
obtain a number of patients suffering from 
cancer. 



CONTENTS 

PAGE 

Introduction i 

Cases of Carcinoma 43 

Cases of Sarcoma 136 



The experimental treatment of cancer bristles 
with difficulties. Some belong to the experi- 
menter and others to the nature of the disease. 
It may seem strange that so many claims 
have been put forward that a cure has been 
found, but to us the explanation is simple, and 
lies in this, that a certain amount of temporary 
improvement can be obtained in quite a number 
of ways. This does not, however, hold good 
in the acute cases. If a doctor has come to 
the conclusion that a certain line of treatment 
may be successful, or accidentally finds im- 
provement after a certain line of treatment, 
and commences to try it on a case where the 
disease is progressing slowly, with at first 
evident improvement, he quickly hopes that 
he has made a discovery. Cases may show 
signs of improvement for a number of weeks, 



2 CANCER 

so that there is time to treat several others 
before the experimenter is able to realise that 
his first case is not doing well. It would be 
such a great thing to discover a cure for this 
disease that it is difficult not to be led away 
by apparent early successes, and the stages 
are, first hope, then belief, and nowadays 
unfortunately too early rushing into print. 

Fortunately for us, our first experiment — it 
was with electricity on a rapidly growing cancer 
of the cervix uteri — relapsed quickly after 
having commenced to improve in a very no- 
ticeable manner. This was twenty years ago 
and was a most useful lesson. It was repeated 
some years afterward when great hopes were 
aroused by Dr. von Mosetig Moorhof that 
the area of infection could be cut off by inject- 
ing pyoktannin round a growth that was cir- 
cumscribed, and in this way make an immune 
ring of tissue. It was tried on a suitable case 
of return in the scar after the removal of the 
uterus by the vaginal route for cervical cancer. 
The injections gave rise to some general dis- 



CANCER 3 

turbance, but the effect on the growth at the 
beginning was extraordinary, and far surpassed 
anything we had seen. Unfortunately the 
result resembled so many others, though we 
had the advantage of obtaining a visit from 
Dr. Moorhof to make sure that his directions 
were being correctly carried out. 

At the present time, with every recognised 
form of treatment, one can only hope for a 
permanent recovery, even after the most ex- 
tensive operations, but the dread of return is 
ever present. Unfortunately there is no cer- 
tainty that the disease will not return; and 
we do not yet, in spite of the promising results 
we have obtained, consider that there is at 
present any certain cure for all cases of cancer. 

So much for the experimenter. The disease 
itself varies in such an extraordinary manner 
that it does not seem to us probable that 
one line of treatment will ever be discovered 
that will make a permanent cure in every 
case. We doubt if any doctor has ever seen 
two cases run an identical course. There 



4 CANCER 

are groups that run on identical lines as com- 
pared with other groups, but individual cases 
vary, and as an extreme instance of this may 
be taken cases of scirrhus cancer of the breast. 
In the case of a fresh-complexioned young 
woman of thirty, the disease will kill within a 
year to eighteen months, no matter how early 
an operation is performed, while an apparently 
similar amount of disease may be discovered 
in a lady of seventy, and if left alone will do 
no harm, though the pathological report of 
both cases would be scirrhus cancer. 

Again, taking these extreme cases, any treat- 
ment of the first must end in disappointment, 
but is safe to this extent, that no undue hopes 
are formed, the disease being so acute, while 
treatment of the second might easily lead the 
experimenter into false hopes. Indeed, a short 
time ago some treatment was advocated on the 
strength of two cases, both elderly men, where 
doubtless the character of the disease had 
evidently much to do with the apparent im- 
provement. 



CANCER 5 

When the disease varies in the extreme way 
that it does, it is impossible for any private 
practitioners to obtain and treat a large enough 
number of cases to be able to dogmatise. 
A sufficient number do not come before him, 
and if they did, he could not afford the time, as 
most would be hospital cases, where at present 
the hospitals do nothing. One has, therefore, 
to bring any promising line of treatment before 
the profession in an unproven and more or 
less immature condition. At the same time 
it is foolish to be in a very great hurry to bring 
forward anything, however promising, until it 
has been tried for several years. 

If there is no return three years after opera- 
tion, it has been arbitrarily taken that the case 
may be considered to be cured. We, as well 
as others, think this much too short a time. 
Still, as three years has been taken as a sort 
of standard, we are of opinion that that should 
be a minimum time to carry on an experiment 
before publishing. 

Improvement is more usually apparent in 



6 CANCER 

cases where there has been a certain amount 
of wasting. Cancer is, as a rule, even in the 
fairly early stages, accompanied by loss of flesh, 
and if this loss can be arrested, which can fre- 
quently be done by treatment which does not 
affect the actual disease, improvement will 
be seen. Along with this improvement in 
the general condition there may be also a 
certain amount of lessening of the size of the 
growth, but when the disease reasserts itself, 
as it must do if no curative agent is brought 
to bear on it, the general health and weight 
quickly go down. Indeed, with many of the 
so-called remedies, temporary improvement is 
gained in spite of the disease. 

When a patient suffering from cancer has 
lost weight, it is essential that the use of the 
remedy alone should result in increased weight 
of the body, not by acting on the general health 
directly, but by lessening the activity of the 
disease and eliminating the cancerous poison 
from the system, and in this way allow the 
patient to recover, part at least, of the weight 



CANCER 7 

he has been losing. It is entirely insufficient 
to treat only the symptoms, but at the same 
time, when any remedy is being used which 
has, or appears to have, a beneficial effect on 
the disease, it is very advisable to assist in 
every way one can to bring up the body weight, 
and, by improving the general condition, place 
the patient in as favourable a position as 
possible to battle against the disease. 

At the present, and not for the first time, 
much attention has been given to the diet of 
patients suffering from cancer. Especially they 
are warned to avoid the use of red meat. This 
is quite right so far as it goes, but if this be 
all, the patient may as well be allowed to eat 
meat once or twice a day if he wants to, for 
abstinence of this kind will not appreciably 
affect the disease one way or another. A 
diet composed principally of beef or mutton 
would undoubtedly cause increased growth. 
It is, however, of the very greatest importance 
to "feed up" the patient, but there is a right 
and a wrong way of doing this. Strong meat, 



8 CANCER 

soups with Burgundy or port wine, may be 
taken as typical of the wrong way of nourish- 
ing a cancerous patient, because it is not a 
quick, stimulating effect, which also stimulates 
the growth, that is required, but a real and if 
possible permanent gain in weight. We are 
no great advocates of too strict a regimen under 
almost any circumstances, and we have found 
that the addition to an ordinary diet of the 
glycerophosphate food Virogen, taken two or 
three times a day, seems to be sufficient to cause 
increase in weight without troubling the patient 
with an elaborate diet sheet. This food has 
the advantage that it is almost, if not quite, 
tasteless, does not require to be cooked, and is 
easily digested. Virogen alone can give but 
temporary improvement, and has no curative 
effect whatsoever, but its use helps greatly to 
improve the general condition. To do any 
permanent good, however, it may be repeated 
that it is essential that the remedy used has 
sufficient action on the cancerous growth to, at 
least, check its debilitating action sufficiently 



CANCER 9 

to allow of some increase in weight, without 
anything special being added to the diet. 
Following up the question of the necessity 
of increasing the weight, it seems hardly neces- 
sary to say that every care ought to be taken 
of the patient to prevent his losing weight. 
When the patient is well enough, there is no 
reason why he should not lead his ordinary 
life, but all active exercise must be avoided 
and the patient must rest as much as possible, 
both bodily and mentally. The amount of 
rest necessary will vary and must be determined 
for each case. As a rough guide it may be 
taken that the quicker the pulse, the more 
rest will be required. The object must be to 
improve the general condition, and an active 
man in fair state of health must not be kept too 
quiet, as the mental effect would not be satis- 
factory. We must always aim at putting 
more strength in than is being taken out. If 
the patient wishes to leave no stone unturned 
to obtain a cure, he must be willing to give up 
everything if necessary. It is not easy, one 



io CANCER 

might almost say impossible, to give exact 
general directions, because what one man 
may gain by giving up his business temporarily, 
another may lose by having too much time 
on his hands to think about his illness. 

It has seemed to us that it is possible for 
a patient to continue to lose weight although 
the visible growth improves. This appears to 
be due to the amount of what may be called 
saturation of the patient with the cancerous 
poison. 

We have now been working on one definite 
line for nearly five years, and believe that we 
have been able to make a foundation for others. 
By means of the treatment to be described we 
feel certain that we have been able to relieve 
pain, prolong life in comfort, and in some 
cases, so far as the time elapsed will show, 
to have cured the disease. This is our belief. 
Putting ourselves in the position of the general 
surgeon who seems to be imbued somewhat 
with the idea that surgery is right and every- 
thing else wrong, we at once say, What about 



CANCER ii 

the diagnosis? If a case has been cured 
without operation and, therefore, without a 
microscopic examination of the growth, then, 
of course, the diagnosis must have been wrong ! 
We ignore the fact that the microscope does not 
always tell correctly, or perhaps we should 
rather say, that what the microscope shows 
has been wrongly interpreted. Therefore it 
will be necessary to bring forward very many 
cases of cure without operation before the 
surgeons will begin to believe in its possibility, 
and the large numbers can only be obtained by 
publishing what we have done and thereby 
inducing others to work on the same lines. 
Putting on one side the cases we believe we 
have cured, there has been a very large amount 
of relief obtained. We do not believe that it 
is advisable to try to prolong life in misery, 
but we do believe that it is worth while to try 
to relieve the sum of human misery, and 
this we have been able to do; life has been 
prolonged and relief obtained in a very large 
percentage of the cases treated. 



12 CANCER 

It is remarkable that when radium was 
first discovered, and almost before more was 
known about it than that it was new and 
expensive, the conclusion was arrived at that 
a cure for cancer had probably been found. 
This conclusion seems to have become a cer- 
tainty in many minds when early improve- 
ment, which has already been referred to as 
common, was reported. It would not be 
possible to have any more conclusive proof of 
the hopeless state of ignorance of everything 
connected with the treatment of cancer. From 
Germany we had a report that a serum had 
been discovered, and it was supposed that 
here at last an advance had been made. It 
was said that one case had been cured and 
that others were doing well. We made in- 
quiries, but could not hear of any satisfactory 
results; there was simply the early improve- 
ment followed quickly by the usual sad ending, 
and the one good case was dead. About the 
same time news came from Paris that a microbe, 
which was always to be found in cases of cancer, 



CANCER 13 

had been located and that a serum had again 
been made. Along with the injection of this 
serum great reliance seems to have been placed 
on surgery, and again there was one special 
case, also dead. The microbe does not seem 
to have any claim to be the microbe of cancer, 
and the serum is a thing of the past. Since 
then we have noticed that yeast has been 
recommended from the same quarter, showing 
that this surgeon is in a great hurry. We 
experimented with yeast for a year ! 

The latest of all the " cures" is trypsin. 
Dr. Beard of Edinburgh found by experiment 
that trypsin was wanting in cases of cancer, 
and about the same time it occurred to Dr. 
Shaw- Mackenzie that there was probably some- 
thing of the kind wanting. It was natural 
to think that a likely experiment would be to 
administer trypsin, and by putting back into 
the system what the cancer apparently took 
out, check or eradicate the disease. This 
seemed such a simple and sensible plan that 
it is not to be wondered at that the originators 



14 CANCER 

were carried away by the early improvements 
and allowed it to go out broadcast that at last 
a cure, and one founded on a scientific basis, 
had been discovered. 

We gave trypsin a very extensive trial, but 
were completely disappointed in its use. We 
also came to the conclusion that it was by no 
means a safe remedy, and in several cases, 
especially in those where there was ulceration, 
it seemed to cause more rapid destruction of the 
tissues and corresponding loss of strength. 

In connection with trypsin it may be noted 
that free hydrochloric acid in the stomach is 
said to be wanting in cases of cancer. Its 
administration does not appear to have any 
effect one way or the other. 

Treatment by X-rays we have not tried 
ourselves, as we consider that good results 
are more likely to be obtained when this treat- 
ment is left to the electrical experts. There 
seems to be no doubt that the rays, properly 
applied, do more in some cases than the 
temporary good so often referred to. Much 



CANCER 15 

harm was done at first and the sufferings of 
many patients were enormously increased by 
the formation of extensive burns. Now the 
treatment is carried out with much greater 
care and knowledge, and at the worst it need 
not do any harm. The usual difficulties of 
the proper selection of cases and obtaining 
them sufficiently early before there is general 
infection are, of course, met with in this as 
with all other forms of treatment. 

It is interesting to compare the different re- 
sults obtained from these two little-known agents, 
radium and the X-rays. Before almost any- 
thing was known of them, both were hailed as 
likely to be curative agents. It has been said, 
"Tell us the cause of cancer and it will not be 
long before the cure will be discovered." This 
is not the course medicine has followed in the 
past. Treatment has always come first, and 
even now, where the cause of a disease has been 
found out, treatment is much more preventive 
than curative. Take typhoid fever, for exam- 
ple : we know how it can be prevented but do 



1 6 CANCER 

we know any more how to cure it than we did 
twenty years ago ? 

With the present state of our knowledge about 
cancer it does not seem that, if we knew the 
cause, we would be very much farther on. At 
the same time any information may be useful, 
and it may be, that the discovery of the cause 
will lead to the discovery of the treatment. But 
what is cancer? What do we know about it? 
If we use the words " malignant disease" to de- 
scribe it, we probably say all that is known, 
a malignant, malevolent disease, and one that 
sooner or later ends in death. There is nothing 
else definite about it, and even this is scarcely 
correct; for, as has been already mentioned, the 
course may run so slowly that the term " malig- 
nant" can scarcely be applied to it. 

There is hardly one question which can be 
asked about cancer which cannot be answered 
and proved both affirmatively and negatively. 
For example, is it hereditary? It is probable 
to some extent that it is, but why should some 
inherit and some escape; and in cases where 



CANCER 17 

there is no history of the disease, how are we to 
be sure that the patient's statement is correct. 
Even at the present day there is a tendency to 
conceal the disease. Fifty years ago this was 
apparently always the case. Cancer was 
looked on with loathing; it seemed to have 
been thought a disgrace, and a thing not to 
be mentioned. We have in several instances 
discovered a strong family history where at first 
the patient was certain that there had never 
been anything of the kind in the family. 

It is generally supposed that cancer is increas- 
ing, and statistics go to prove that this is so; 
but can we be sure of our statistics ? It has been 
already said that any case cured without opera- 
tion and microscopical examination is looked 
upon with a large amount of doubt. If this is 
so about cases where every possible care has been 
taken, is it not also probable that statistics are 
open to doubt from the same reason? Besides, 
medical education has so enormously improved 
in the past twenty or thirty years, that when 
statistics of the present day are compared with 



1 8 CANCER 

those of some years ago, the comparison is 
made between two sets founded on very differ- 
ent foundations. If the disease is really increas- 
ing, a very promising starting-point for the in- 
quiry into its cause is at hand. The question 
one is most frequently asked after that of 
heredity is, whether there is any risk of infec- 
tion. We do not believe that there is any, and 
we have never seen anything which would cause 
us to doubt the statement that there is no risk, 
but the question crops up now and then, and 
occasionally it appears to receive a certain 
amount of support from medical men. 

Is cancer more prevalent in one locality than 
in another ? Statistics rather point to this being 
the case, but the evidence at present is not 
very strong. 

A vexed question is that of the nature of 
the disease: is it a local condition, or is it a 
general one? By taking individual cases it 
can be conclusively proved that it is both 
general and local. Taking our former example 
of the young healthy woman with rapidly 



CANCER 19 

growing cancer; early operation, no matter 
how early, totally fails to even check the dis- 
ease in this special type of case, therefore the 
disease may certainly be said to be a general 
one. But it as certainly must be a local one 
if we reason from the case of removal with no 
return many years afterwards. It seems to 
be most generally held that the disease is a 
local one and is more likely to occur in those 
who have a predisposition to it; i.e. have a 
family history. In the great majority, the 
predisposition is not sufficiently great to cause 
recurrence if the disease is removed early, 
unless the patient is placed under similar 
circumstances to those which were present 
when the disease started in the first place. 
If the disease were not frequently a local one 
in the beginning, surgery would be of little use 
except to remove symptoms; but as many 
cases are, so far as is known, permanently cured 
by operation, there can be no doubt on this 
point of the local nature of the disease in many 
cases. Many doubt the curability of cancer 



20 CANCER 

by operation, but it is a certainty that it can 
be done in certain cases. The difficulty is 
to know beforehand which cases are likely to 
recover, and in which there is a likelihood that 
there will be a return. The first would natu- 
rally be the most suitable for experiment. A 
case which we have reported elsewhere points 
strongly to the local nature of the disease, 
with a tendency to return only under special 
circumstances. We removed a breast for a 
scirrhus cancer which had been growing for 
two years. The axilla was not cleared out. 
A year afterwards the patient received a slight 
blow on the chest as some one was helping 
her on with her cloak. A small nodule ap- 
peared near the scar and was removed. In 
another year, while dancing up and down a 
little child, a blow was received from the 
child's foot, and a second nodule had to be 
removed. Ten years after this operation, a 
third nodule had to be taken away, an old 
aunt who was insane having struck the patient 
with her elbow. It would be interesting, 



CANCER 21 

though of course impossible now to know, 
if a very extensive operation had been per- 
formed in the first place, what would have 
happened. Would there have been no return, 
or would the first injury, acting on a part de- 
vitalised by loss of nerve supply, have lit up 
the disease acutely? Certainly clearing out 
the axilla would have had no effect one way or 
the other. If the cancer were entirely local, 
extensive operation might have prevented 
recurrence, while, on the other hand, if there 
were any general tendency, recurrence might 
have been more serious. Isolated cases such 
as this one can be made to prove anything, and 
the more one compares single cases, the more 
difficult it is to come to any conclusion. It is 
for this reason that we hold that it is essential 
to have an enormous number of successes 
before it can be claimed that a means of cure 
has been discovered, and this is why we are 
anxious that the treatment we advocate should 
have a wide trial. Could we have carried it 
to a successful conclusion ourselves, we would 



22 CANCER 

have preferred to do so, but this would have 
required an unlimited amount of time to devote 
to the subject and an unlimited amount of 
material, such as is at present wasted, fortu- 
nately through no one's fault, at the hospitals 
and dispensaries all over the country. 

The symptoms vary and the character of 
the disease varies so much that it is difficult 
to make comparisons. They vary with the 
part of the body in which the disease is situated, 
and with its rapidity of growth; or they may 
be due to the mechanical presence of the 
growth, or to something in the mass itself. 
In some parts, there may be ulceration, in 
others there may be pain actually in the growth, 
or from pressure causing pain or perhaps 
dropsy of a limb. On the other hand, there 
may be little or no pain, simply progressive 
weakness, which is said to be even more dis- 
tressing than actual pain. Emaciation may 
be the most noticeable symptom. Among the 
laity it is commonly supposed that there is a 
special expression or appearance which denotes 



CANCER 23 

cancer. The so-called cancerous cachexia is 
not of much importance, as it does not appear 
in the early stages, but only when the disease 
is well advanced. 

It is impossible for any one experimenting 
with the treatment of malignant disease to 
have very good results, because only the worst 
kind of cases and ones which have already 
tried the recognised methods of treatment 
come before him. Even if one did happen 
to have a succession of early cases, it would 
not be easy to advise an experiment rather than 
removal of the growth followed by the treat- 
ment. It is very seldom that a patient abso- 
lutely declines operation unless under special 
circumstances, such as some intercurrent dis- 
ease. One sad case occurred a number of 
years ago in the practice of the late Dr. Thomas 
Keith. A lady consulted him on account of 
a typical cancer of the breast, the case not 
being a particularly favourable one for opera- 
tion. She was very anxious to live until a 
certain date, as if she died before that time, 



24 CANCER 

her children would be unprovided for, and 
what she was specially anxious to know was, 
whether he considered that her chance was 
better, taking into consideration the risk of 
operation, if she had the growth removed or 
not. He very strongly advised operation, and 
even at that time, before the days of Listerism, 
was able to tell her that he had never had a 
death after this operation; but she was afraid, 
and in the end elected to try and live out the 
time without running the operative risk. She 
failed by a very few weeks, but doubtless 
would have been glad to try any experiment 
which did not involve risk. It is very dis- 
couraging when case after case comes late, and 
one sees a number where one should harden 
one's heart and decline to try anything. Yet it is 
difficult, both because patients are so anxious 
to try something, and also because it is difficult 
to know when a case is absolutely hopeless : one 
such will be found recorded in No. XXII. 
It is hardly possible to give even general 
rules as to which cases to reject, so much de- 



CANCER 25 

pends on the experience one has gradually 
obtained; but it may be said that patients 
much over sixty-five years of age and who 
look their age are not likely to turn out satis- 
factory cases. If the pulse is much over 100 
a minute, the case is not favourable, and if 
treatment does not bring it down to 80 within 
a month, it is probable that the result will not 
be good. The quick pulse must be taken as 
an indication that the disease is in a well- 
advanced state, with more or less general in- 
fection. Any one who is much emaciated must 
be looked on as doubtful for the same reason. 
There are some cases which must be left ab- 
solutely alone, — ones where the disease has 
advanced so far and the vitality is so low that 
the patient cannot live more than a very short 
time ; but it is not always easy to tell such 
cases, and when in doubt, unless there is much 
pain, it is probably best, on the whole, to leave 
the case alone and not run the risk of raising 
false hopes. 
To come back to the question of diagnosis : 



26 CANCER 

this will keep back at least for a time any 
experimental treatment, because in all acces- 
sible parts diagnosis is more easy and certain, 
than it is in those cases where the disease 
is situated either in the chest or abdomen. 
Besides, in the more get-at-able parts oper- 
ation is more readily advised and agreed 
to. Internal growths, as being either less 
accessible to surgery or beyond its reach alto- 
gether, are, therefore, more likely to be treated, 
and if the patient recovers, there will always 
be the doubt as to the nature of the growth. 
It is also the case that such internal growths are 
not as a rule discovered until the disease is well 
advanced. We are prepared for its being said 
that the cases we have considered ourselves to 
have cured have been made well because there 
was an error in diagnosis. This does not alter 
the fact that patients condemned to die by others 
have been cured by means of our treatment. 

When treatment is attempted after surgery 
has failed to cure, this failure shows that the 
disease has either always been or has become 



CANCER 27 

of a general nature and is therefore more 
difficult to deal with. In such cases the diag- 
nosis has already been made. 

Treatment may also be given immediately 
after an operation to increase the chance of a 
permanent cure, and there can be little doubt 
but that this is a good thing to do when treat- 
ment does not involve any risk. Naturally 
treatment is most likely to be successful after 
a first operation than it would be after several 
secondary ones, but the difficulty would then 
be to know where the credit was to be given, 
to the operation or to the treatment. To 
treat after a return, or a second operation, 
would, from the purely interesting point of 
view, be the more satisfactory way, but would 
not be so good for the patient; and if a cure 
resulted, there would still be doubt, though a 
much weaker one, for the second operation 
might have been more successful than the first. 
To a certain extent this may be compared to 
the operation for appendicitis. If the opera- 
tion is performed after the first attack, we 



28 CANCER 

cannot be sure, as a rule, that there would have 
been a second attack of inflammation. 

Whichever way you look at it, there are 
difficulties, and it is very perplexing to know 
what is the best thing to advise. One has 
only to give the advice which seems best; 
statistics and proofs will come later. 

Attention must be given to the part of the 
body affected, and we are inclined to think 
that treatment will follow on this line rather 
than on exact microscopic differentiation, though 
this is perhaps only another way of saying 
that the pathological condition varies with the 
situation of the disease. We have found, 
for example, that X-rays appear to have a more 
beneficial effect on a cancer primarily in the 
skin than does our treatment by injections. 
Cancer largely involving a vital organ, as, for 
example, the stomach, is much more difficult 
to treat by any method than it is when the 
disease is situated in a part of the body less 
necessary to life. For our treatment we very 
much prefer to have to do with cases where 



CANCER 29 

there is a distinct growth as distinguished from 
cancerous ulceration. Certainly in Case XXX, 
which was probably a cancerous ulceration of 
the tongue, the disease has been cured, but 
this case was treated in a very early stage, and 
this one case is in no way sufficient to counter- 
balance our opinion that a permanently good 
result is not to be expected in the ulcerative 
cases. The treatment by X-rays either alone 
or in combination would probably be more 
likely to effect a cure. 

In the present state of our knowledge we 
do not think it advisable to leave any growth 
which can safely be removed, unless perhaps 
the disease has been discovered in an excep- 
tionally early stage. In such a case the delay 
of three or four weeks would, at the very worst, 
not do much harm, and several such cases would 
do more to show what the treatment was worth 
than almost any number of late ones. It would 
not be necessary to carry on the treatment for 
so long a time as a month unless there were 
marked improvement very quickly. 



30 CANCER 

The treatment which we are anxious that 
some of the profession should try, — and we hope 
that when it is tried the attempt will not be 
limited to one or two cases, because, as we have 
already said, we do not expect any one line of 
treatment will cure all, — may be described as 
in a way old and in one respect new. Among 
the many drugs we have experimented with 
in the past is the commonest of all cancer 
remedies; viz. arsenic. It was given as a 
routine treatment in Edinburgh twenty-five 
years ago in inoperable cases, and apparently 
gave a certain amount of relief. Having this 
in mind, we tried it hypodermically shortly 
after this method of its administration came 
to us from Italy. There was quite a con- 
siderable amount of difference in the effect 
obtained when given by the mouth and when 
injected. The immediate improvement after 
injection was decided and pain was lessened, 
but this gain proved to be only temporary, and 
the experiment was not gone on with for a 
long time. Iodine is a drug of which great 



CANCER 31 

things seem to have been expected years ago, 
though not in the treatment of malignant 
disease, and when Merck of Darmstadt put 
iodipin on the market, we thought that it was 
worth while giving it a trial. The results 
were somewhat similar to those obtained by 
the hypodermic injection of arsenic. It oc- 
curred to us to combine the two. Immediately 
there was so much change for the better that 
we took this combination as a basis. Along 
with it, either separately or in combination, 
we have tried a great number of other agents, 
some with a reputation in the treatment of 
cancer, others not. For example, we used 
trypsin for a year, hypodermically and sepa- 
rately of course, before we finally discarded 
it as being not only useless but also dangerous. 
Yeast was also tried for about a twelvemonth. 
Without exception we tried these two — trypsin 
and yeast — for a longer time than any of the 
others, the first because it really seemed to be 
so scientifically correct, and the second because 
it ought to have done good if the theory on 



32 CANCER 

which we were working had proved to be a 
correct one. Now we have given up all theories 
and limit ourselves to trying to relieve or cure 
this disease. 

Some years ago Dr. Lovel Drage wrote a 
most interesting paper on the treatment of 
cancer with cinnimate of sodium. This, like 
arsenic, is one of the drugs which formerly 
had a reputation in the treatment of cancer. 
Dr. Drage's injections were followed by a 
reaction. We tried the cinnimate of sodium, 
but failed to obtain Dr. Drage's results, but 
this may be because we did not follow his 
directions exactly, as we tried and succeeded in 
avoiding the reaction. This drug is the only 
one we have found to be a help when added 
to the arsenic and iodine. 

At first, we began with a small dose of the 
arsenic, twenty minims of the ordinary hypo- 
dermic injection of arseniate of iron. We tried 
doubling the strength of the arsenic injection, 
doubled again, and then again, but the last in- 
crease in strength did not appear to be of any 



CANCER 33 

assistance. In only one case has there been 
any symptom of arsenical poisoning, and even 
then the symptoms were slight. Messrs. Squire 
have now made for us the injection in two 
strengths, which will be more fully described 
later. It may be more satisfactory to give 
exact directions for making the injection from 
the separate ingredients with what we con- 
sidered a standard dose. This strong stand- 
ard injection consisted of a solution of iodipin 
in oil, arseniate of iron, cacodylate of iron, 
and cinnimate of sodium. The iodipin is a 
25 per cent solution in oil. 

The arseniate of iron contains \ gr. of iron 
and ^g- gr. of arsenious anhydride in 1 c.c. 

The cacodylate of iron contains 3 gr. of iron 
in 1 c.c. 

The cinnimate of sodium is a saturated 
solution containing \\ gr. to the cubic centi- 
metre. 

The emulsion which is formed is a mechani- 
cal mixture and is not a new compound. 

The average proportions of the emulsion 



34 CANCER 

which we have used most are as follows: one 
drachm of the iodipin and twenty minims each 
of the other three. If the mixture is made by 
shaking by hand, it is advisable to thoroughly 
shake together the iodipin and cacodylate 
first, then add the cinnimate of sodium and 
finally the arseniate of iron. The reason for 
mixing in this order is simply that it saves a 
great deal of shaking. If the mixing is done 
by machinery, all the ingredients can be put in 
together. These proportions may be taken 
as a standard, but we are accustomed to vary 
them materially in some cases. This is a 
matter more of experience than anything else; 
it is difficult to give even general directions, 
but it may be taken as a general rule that in 
all abdominal cases the amount of arsenic 
should be lessened and in uterine ones increased. 
The dose varies also. Some patients appear 
to do well with 5 c.c. of the emulsion given every 
second day or even every day, while it seems to 
be advisable with others not to give more than 
2 or 3 c.c. This is also very much a matter of 



CANCER 35 

experience. One indication of the strength of 
the dose is to be found in the immediate effect 
of the injection. If the patient feels sick at 
once, it is probable that the dose is too large, 
and we are accustomed to reduce it to the 
point which will avoid this feeling of nausea. 

Sooner or later a more or less strong odour 
of garlic will be noticed in the breath; in 
some, it is very noticeable, and as a rule the 
odour does not appear in the early stages of 
the treatment and only when the disease has 
begun to improve. We hoped that some 
indication would be obtained from this sign; 
for if the injection is used in a non-malignant 
case, the odour is very strongly noticeable 
after the first injection. This we discovered 
in the experiments on ourselves. Like every- 
thing else connected with the disease, the 
appearance of the odour is not to be depended 
on, as occasionally, though very rarely, it 
appears at the beginning of the treatment of 
a case of undoubted cancer. 

With the exception of the feeling of nausea 



36 CANCER 

if the dose is too large, and the odour of garlic 
in the breath, the injections should not have 
any disagreeable effects. 

Any serum syringe can be used. We have 
found Record's as convenient as the all glass, 
and while it can be kept clean as easily, it is 
not nearly so liable to break, and this is a con- 
sideration in several ways. Another objection 
to the glass is that spicules of glass are apt to 
crack off from the end of the piston and, passing 
in with the injection, set up irritation and lead 
to the formation of an abscess. The needle 
should be kept very sharp, as it makes a great 
difference to the patient; it should also be put 
in quickly. It may seem unnecessary to go 
into such trifles, but it is really wonderful what 
a fuss can be made over a little matter like this 
of an injection. When they are being repeated 
often, little details are worth attending to. It 
is not always easy to keep the needles sharp. 
Apparently there is a difficulty in getting a 
good edge all round, and if several are sent 
to the instrument maker at a time, a pro- 



CANCER 37 

portion will come back no better than when 
they went. 

Thorough bathing with very hot water after 
an injection helps to prevent bruising and keeps 
the parts soft ; or a good liniment may be rubbed 
in. The injections are to be made subcutane- 
ously, not into muscle, as with the arseniate of 
iron alone. The most convenient place, as a rule, 
is the outer part of the upper arm ; next in order 
come the buttocks, abdominal wall, and outer 
parts of the thighs. But the best plan is to try 
to find the part which gives least trouble. 

The injection can hardly be put in too slowly. 
When it is injected quickly, it is apt to make 
a hard swelling and causes much more pain. 
The very great majority of patients say that 
there is little pain when the treatment is carried 
out carefully. It is unnecessary to put on any 
dressing; but should there be oozing, a small 
piece of sticking plaster may be used. 

We aim at a cure, but in the present state of 
the treatment we do not expect that one can 
be obtained often, at least so long as the treat- 



38 CANCER 

ment has to be carried out on very advanced 
cases such as we have had to deal with up to 
the present. 

Putting aside the possibility of cure altogether, 
the treatment has great advantages; and it 
does not interfere with any other method of 
treatment. In several cases we have combined 
it with the use of X-rays ; in one with decided 
benefit, though in another severe suppuration 
resulted from their use. With very few ex- 
ceptions there is always, at the very least, the 
temporary improvement which seems to be 
common to so many forms of treatment, but 
this improvement, when it is not permanent, 
lasts much longer than in any other form of 
treatment we are acquainted with. In other 
words the natural expectation of life is pro- 
longed, though, of course, this must be a matter 
of opinion unless the time gained is very well 
marked. We had a good example almost as 
this was being written. The husband of a 
lady who had been unsuccessfully operated 
on six months before for abdominal cancer 



CANCER 39 

asked a doctor who had seen the case at the time 
of operation what condition he would expect 
his wife to be in, and the answer was that he 
would expect that she would be sinking. In- 
stead of this she was steadily gaining weight at 
the rate of one and a half pounds a week, due 
presumably to the injections. Roughly we 
would be inclined to put the prolongation of 
life at, on the average, double what it would 
have been. The patient lives longer, and at the 
time when he would have been on his death- 
bed, he is in good health, and then when the 
end comes, it comes more quickly and much 
more easily. 

Pain is such a common symptom of cancer 
that its relief without having recourse to mor- 
phia is a great boon. We do not know why 
these injections should relieve the pain of can- 
cer, but they do it in a most wonderful manner 
when the pain is in the growth itself. One 
injection will often give considerable relief, 
and less than half a dozen will remove the pain 
entirely in the great majority of cases. This 



40 CANCER 

relief can only be expected to come so quickly 
when the pain is actually due to the cancer itself 
and not when it is due to pressure or when the 
disease is of an ulcerative character. In such 
cases the pain is relieved more slowly, as one 
would naturally expect. 

We would strongly recommend the use of 
the injections after operations. No surgeon 
is in the position to say after any operation for 
cancer that there will certainly be no recurrence. 
He may tell his patient that the disease has 
been so thoroughly removed that it can never 
come back, but he knows in his own mind 
that the patient is not safe. There seems to 
be little objection to using the treatment after 
operations. Twenty-five or thirty injections 
do not inconvenience the patient much; they 
give him confidence that the tendency to recur- 
rence has been lessened, even though he knows 
that the disease has been most satisfactorily 
removed. The treatment does not keep him 
away from home, as his own family practi- 
tioner is as able to give the injections as the sur- 



CANCER 41 

geon who performed the operation; and alto- 
gether, while there is little to lose, there may 
be a great deal to gain. It has already been 
pointed out that it is impossible to prove that 
he gains immunity, as that may have been al- 
ready given by the surgeon, but most patients 
do not trouble much about such things : to be 
cured is sufficient. 

We have made no experiments on animals, 
as malignant disease seems to be one of the 
diseases which varies so much that it cannot 
be compared in animals and in human beings. 
It does not appear, therefore, that much is to 
be gained by attempting to cure malignant 
disease in an animal, in the hope that if this can 
be done, a similar line of treatment will tend 
to cure human beings. This is, however, one 
of the methods which is looked upon as scien- 
tific at present, and being scientific, any infor- 
mation gained by this means, is supposed to 
be of more value than any which may be de- 
rived from empirical experiments on human 
beings. This does not affect the question of 



42 CANCER 

vivisection in the slightest, though, had we tried 
the injections first on an animal rather than 
on ourselves, we would have been brought 
under the law as violators of the antivivisection 
act! 



CASES OF CARCINOMA 

Case I, a widow aet. 60, had been a hard- 
working woman all her life, but had to give up 
her work, that of a domestic servant in a board- 
ing house, four and a half months before she 
was seen on the 19th of May, 1903. She had 
first noticed some swelling of the breast rather 
more than six months before, but when she 
went to the Cancer Hospital in the middle of 
April, the disease was too far advanced for 
operation. She attended as an out-patient 
once a fortnight, but it was very evident to her 
that she was not wanted. A week before we 
saw her, she had gone to Charing Cross Hos- 
pital, and the friend who accompanied her was 
told that it was a very bad case of cancer, that 
she would not live more than six weeks, and that 
it was hopeless to do anything. She had to 

give up her work partly on account of the pain 

43 



44 CANCER 

in the growth, partly from feeling too weak to 
do much, and also on account of not being 
able to move her arm easily, as the growth in 
the breast projected far into the axilla. 

She had had rheumatic fever twice when 
young, there was a loud aortic bruit, and she 
was a martyr to chronic bronchitis. 

So far as she knew none of her relations had 
died of cancer, but she did not appear to 
know much about any of them. 

On examination, the growth was found to 
be a very large typical scirrhus cancer of the 
breast, measuring 8| x 7 inches, and it had 
projected into, and filled the lower part of the 
axilla. As this part became reduced in size, 
it was found that there was a large mass under 
the pectoral. There were a few slightly en- 
larged glands in the upper part of the axilla. 
The skin was broken to the extent of 2 inches 

by 1*. 

Injections of 5 c.c. were begun at once and 
were repeated daily; they did not contain the 
cinnimate of sodium, and the arsenic was weak. 



CASES OF CARCINOMA 45 

When the patient came the second day, she 
mentioned that she had had less pain. We were 
not inclined to lay much importance on this 
statement, but when at the end of a week she 
said that the pain had completely disappeared 
and that she was feeling in every respect better, 
it was encouraging. On the 4th of July, six 
weeks after the treatment was begun, the woman 
went back to work, and her mistress said that 
her work was hard, as they were very busy 
at the time. On the 27th of August, she had 
to give up on account of shortness of breath. 
On the 29th there were symptoms of heart 
failure, and she died two days later. The doc- 
tor who saw her did not consider that the can- 
cer was active, though there was a large mass 
remaining, approximately about one-half the 
size it had been three months before, but he 
ascribed the death entirely to the condition of 
the heart. 

What is most noticeable in the case is the 
wonderful relief from pain and the temporary 
improvement in health and strength in spite 



46 CANCER 

of the condition of the heart. On the 19th 
of May this patient was suffering great pain, 
was unable to work, and was simply waiting 
for death to release her from her misery. The 
treatment freed her from pain, and allowed her 
to work until within four days of her death; 
under all the circumstances not a very bad result. 

Case II, aet. 59, was seen on the 30th of 
June, 1903. This was an example of a slowly 
growing cancer, as the right breast had been 
removed ten years before. Since then there 
had been seven operations. The patient was a 
soft, lymphatic woman, much subject to bron- 
chitis and with a chronically dilated heart. 
To say that her tissues were waterlogged, per- 
haps best describes her condition. 

Five nodules were to be seen, — one in the 
scar, one in the pectoral, two above the scar 
near the axilla, and the largest, the size of the 
last joint of the thumb, was above the clavicle. 
The doctor who had performed the operations 
had said that nothing more could be done, 
and with this we were entirely in accord. 



CASES OF CARCINOMA 47 

In the first twelvemonth, seventy-six injec- 
tions were given. All the nodules had become 
smaller, and the one in the muscle had dis- 
appeared. On former occasions the growth 
had been rapid and the patient and her friends 
were much surprised at the difference. The 
general health had been fairly good, but the 
patient was much handicapped by the condi- 
tion of the chest. In February, 1905, one 
nodule was a little larger, otherwise there was 
no change. In the end of March, the patient 
died quietly in her sleep. It is difficult to say 
how much the treatment did for this patient. 
It certainly prolonged her life and improved 
her general health, while the disease, so far as 
could be seen, was held in check. The patient 
was a very bad subject for any treatment, and 
on the whole, the result may be considered 
not altogether unsatisfactory. 

Case III, aet. 32, was seen in September, 
1904, and the following history was obtained. 
A swelling was first noticed in the left breast 
in October, 1903. This was diagnosed to be 



48 CANCER 

an innocent growth, and nothing was thought 
of it until the patient was seen again in the 
end of March, 1904. The breast, axillary 
glands, and part of the pectoral muscle were 
removed in April, and in July a second opera- 
tion was required. Both operations were per- 
formed by a well-known surgeon. 

Injections were begun in September, though 
the husband was warned that the case was a 
very unfavourable one, as, in our opinion, it 
was typical of those where the disease returns 
quickly in spite of all treatment. Already, 
two months after the last operation, there 
were three nodules in the muscle, and one near 
the scar. The odour of garlic was very notice- 
able even from the first injection. 

The treatment did not appear to have any 
beneficial effect on this case, though there was 
perhaps a little improvement at first, but not 
sufficient to be of any account, and the patient 
died toward the end of November, one month 
over the year after the growth was first noticed. 

Case IV, aet. 33, was seen on the 24th of Sep- 



CASES OF CARCINOMA 49 

tember, 1903, with a hard ulcerating scirrhus 
cancer of the right breast. 

Her mother had died of cancer. 

The patient complained of discomfort rather 
than of pain; she had lost flesh, and felt weak 
and miserable. On examining the breast, a 
hard mass the size of a billiard ball was felt. 
The growth was adherent to the ribs. There 
were also two ulcerations, the larger one the 
size of a shilling. The axilla was filled with 
enlarged glands and a few nodules could be 
detected under the pectoral muscle. No en- 
larged glands could be found in any other 
part of the body. 

The patient stated that she had noticed the 
growth for about one year, and that latterly 
she had fallen away rapidly. She had con- 
sulted four doctors, and all were agreed that 
the case was too late for operation, and advised 
that nothing could be done. 

Fifty-nine injections were given in all, the 
first on the 24th of September, 1903, the last 
on the 3d of May, 1904. 



50 CANCER 

The ulcerations had healed by the month 
of December, and on examination in August, 
three months after the last injection, not a 
trace of disease could be found anywhere. 

There has been no return in spite of the prog- 
nosis of one hospital surgeon that the patient 
would not live more than six months. The 
case progressed so steadily and so satisfactorily 
that it is impossible to say very much about it 
except that on the 12th of October, 1904, the 
ovaries were removed on account of severe 
menorrhagia. We feared that if the general 
health got too much below par there might 
perhaps be return of the malignant disease. 
It is possible that the removal of the ovaries 
has assisted in preventing the return of the can- 
cer, but of this there is, of course, no proof 
one way or the other. 

The patient made an uninterrupted recovery 
after the operation and is at present in the best 
of health. She still, however, feels that her 
right side is stiff when she stretches out her arm. 

Case V, aet. 59, was seen on the 5th of No- 



CASES OF CARCINOMA 51 

vember, 1903. In February she noticed a small 
lump the size of a sixpence near the right nipple. 
In July she was admitted into a general hos- 
pital, and after a general consultation, was 
advised to have nothing done, as the growth 
was increasing slowly, though, strangely enough, 
she was not asked how long it had taken to 
grow! The patient was soft, fat, and very 
wheezy. The pulse was 98 and she was sel- 
dom free from bronchitis. There was well- 
marked emphysema, and the heart was dilated. 
Three sisters had died of internal disease, 
supposed to have been of a malignant nature. 

On examination, the nipple was found to 
be flattened out, and was the centre of a very 
hard mass slightly over two inches in diameter, 
dark purple in colour, and surrounded by 
numerous deposits in the skin of varying size. 
The skin deposits were to be found as far as 
from four to five inches, in all directions, from 
the nipple. There had never been any pain. 

Sixty injections were given, and their use 
resulted in great reduction in size both of 



52 CANCER 

the main mass and of the nodules, but not a 
single nodule entirely disappeared; some be- 
came invisible, but the hardness always re- 
mained. The patient died of bronchitis and 
heart failure after a few days' illness. It 
seems that this would have been a suitable 
case to have combined the X-rays along with 
the injections. 

Case VI, aet. 59, was seen in the end of Febru- 
ary, 1904. A year or two previous to this time 
she had consulted a doctor about a little irrita- 
tion of the left nipple. Her attention was called 
to the breast by darting pains, and also by 
noticing that it was getting larger. Originally 
the left had been decidedly smaller than the 
right. 

On examination on the 22d of February, 
a large, ill-defined, hard, flattened mass was 
felt in the upper and outer part of the breast, 
extending from the nipple, which was drawn 
in, to the outer margin of the gland. In the 
axilla there was a second ill-defined mass, and 
the skin over it was puckered and adherent. 



CASES OF CARCINOMA 53 

The patient was informed that she had cancer 
and that an operation was advisable. While 
none of her immediate relations had had the 
disease, several of her friends had, and the re- 
sults of their operations had been so unfortunate 
that she declined even to consider anything 
surgical. Treatment was begun on the 26th 
of February, 1904. 

The pain was relieved after the sixth injec- 
tion. Forty-five were given by the 9th of 
June, and there was a second course in Sep- 
tember. The growth slowly diminished in 
size until there was hardly more than a small 
atrophied breast containing a small, apparently 
fibrous nodule. In the beginning of 1905 the 
patient began to become anaemic without any 
apparent reason. In May, however, ascetic 
fluid was found to be accumulating in the 
abdomen, and some irregularity in the outline 
of the liver was discovered. The abdomen 
had to be tapped, and on examination of the 
deposit, a few malignant cells were found. 
The patient lived into July. 



54 CANCER 

Whether the disease was present in the 
liver at the time the growth was discovered 
in the breast, we have no means of now 
knowing. No post mortem examination was 
allowed. 

Case VII, aet. 59, a widow, was first seen 
in July, 1904. Her right breast had been 
removed in Edinburgh for cancer three years 
before, and the disease returned in the scar 
a year afterward. There was no family his- 
tory of cancer to be obtained. She suffered 
from severe pain, to ease which "high fre- 
quency" had been used without giving any 
relief. The patient was extremely emaciated, 
looked ill and weak, and the pulse was 112. 
There were several hard nodules adherent to 
the skin and ribs, varying in size from a pea 
to a small walnut. The axilla was full of en- 
larged glands, and those in the right side of the 
neck were in a similar condition. There was 
very well-marked bulging of the ribs with com- 
plete loss of resonance in front of the whole 
upper part of the chest on the right side. The 



CASES OF CARCINOMA 55 

case seemed a hopeless one, and the patient 
was advised to go home, but she begged very 
hard to have something tried to relieve the 
pain. The first injection gave partial relief, 
and complete freedom from pain came after 
the tenth. 

The nodules became smaller, and the pulse 
slowly fell till its rate was 72 to the minute 
after the thirty-fourth injection. 

The patient went home to Scotland on the 
31st of October, having had forty- three injec- 
tions. She had put on a little weight — eight 
pounds — and said she felt well ; there was no 
dulness over the chest, and one nodule only 
remained. The glands both in the axilla and 
neck could barely be felt. 

It was arranged that the treatment was to 
be recommenced after an interval of two months, 
but the patient wrote to say that she felt so 
well that she would not come back to London 
so long as she felt as she did unless the pain 
returned. She was one of the people who 
always know best about everything, and her 



56 CANCER 

relatives could not persuade her to move from 
home. 

In March, 1905, she got an attack of bron- 
chitis, and died quite suddenly, apparently 
of heart failure. There had been no return 
of the disease, nor had there been any pain. 

The treatment gave this patient relief from 
pain, and good health for seven months, and 
she died from an intercurrent illness, her life 
having been prolonged in comfort to twice what 
would have been the natural expectation. 
That there must have been some very decided 
effect on the actual disease was shown by the 
disappearance of the nodules, the slowing of 
the pulse from 112 to 72, and the gain in weight. 

Case VIII, aet. 63, was seen first in July, 1903. 
In the previous October a growth was first 
noticed in the breast ; the arm swelled in Janu- 
ary, 1903, and in March the red projection to 
be described appeared. There was no family 
history of cancer. 

On examination, a large, hard mass, taking 
in practically the whole of the left breast and 



CASES OF CARCINOMA 57 

running continuously to the top of the axilla, 
was found. On the breast there was a pro- 
jection of a dark purple colour nearly two 
inches in diameter. The hand and arm were 
much swollen and were painful. Operation, 
which seemed to be just possible, was declined 
absolutely, and injections were agreed to in- 
stead. Contrary to our usual experience, they 
gave a great deal of trouble, hardly one being 
given without causing pain and swelling. The 
patient had lived much in the East, and stings 
from insects were always more trouble to her 
than to most people. 

By the end of September, twenty-seven 
injections had been given, with the result that 
the growth seemed to be about one-half smaller. 

In November the patient was much alarmed 
by a severe haemorrhage from purple-coloured 
swelling, and consented to have the breast 
removed. The most noticeable point about 
the operation was that there was very little 
bleeding. To the naked eye the blood-vessels 
appeared to be surrounded by an unusual 



58 CANCER 

amount of fatty tissue. The microscopic ex- 
amination was as follows: sections were pre- 
pared from (a) the superficial mass, i.e. the 
purple outgrowth, (b) from deposit just below 
surface, and (c) from deposit in depth of gland. 

(a) This section presents all the appearances 
of a rapidly growing carcinoma. It possesses 
no unusual features. 

(b) This section is interesting chiefly on 
account of the large amount of small cell 
infiltration present. Areas of carcinoma in- 
vaded by small cell infiltration are quite con- 
spicuous. There are also traces of degen- 
eration present. 

(c) Identical with b. 

The interest of the case ends with the micro- 
scopical examination, as the patient became 
jaundiced in March, and died shortly after- 
ward. 

Case IX, aet. 65, consulted us in June, 1904. 
Two sisters had died of malignant disease, 
and in May, 1903, the right breast was removed 
for cancer by a first-rate provincial surgeon. 



CASES OF CARCINOMA 59 

The return of the disease was rapid, as a 
second operation was required in four months, 
a third in December of the same year, and a 
fourth in May, 1904. Thus the malignancy 
was great, shown by the necessity for four 
operations within thirteen months. 

In June, 1904, no definite growth could 
be felt, but the arm was very decidedly swollen, 
and there was a considerable amount of pain 
below the clavicle. Nothing could be seen 
or felt beyond a little fulness in the axilla and 
upper part of the right side of the chest. Thirty 
injections were given. The pain was entirely 
relieved after one-third of the course. In 
January, 1905, a small nodule appeared in 
the skin below the clavicle, and twenty-two 
injections were given. 

In May, the lower ribs on the right side ap- 
peared to be much pushed out, and there was 
a dull note on percussion. Eighteen injec- 
tions cleared up the dulness and got rid of the 
projection of the ribs. In July, the patient 
said that she could do more than she had been 



60 CANCER 

able to do for years. In August, a hard growth 
in the skin, the size of a shilling, situated low 
down on the chest wall, was removed. This 
was the first operation in fifteen months, show- 
ing that the degree of malignancy had been 
much reduced. In November, a nodule deep 
in the neck above the clavicle, and two in the 
skin below the bone were noticed, and the 
patient was persuaded to have X-rays in addi- 
tion to the injections. 

By November, 1906, three courses of injec- 
tions, nineteen at a time, and X-rays, had been 
given, and the result was that the patient was 
very nearly holding her own, but not quite. 
The disease in the neck was evidently checked, 
but before each course there was considerable 
dulness of the chest, which, however, always 
cleared up. The swelling of the arm was less 
than it had been for two years. 

In July, 1907, the patient had had three 
courses, and shortly before she came to town 
the last time, the skin had broken near where the 
operation was performed two years before. The 



CASES OF CARCINOMA 61 

ulceration healed under treatment. Shortly 
after going home the patient suffered from 
heart weakness. 

Case X, aet. 50, a great beer-drinker, had 
a large scirrhus cancer of the right breast re- 
moved in hospital on the 31st of December, 
1902. The case was one where a permanent 
recovery might well have been expected, as 
the patient was in good general health, showing 
that the disease was at that time almost cer- 
tainly local, and on microscopic examination 
it was found that the malignant growth did 
not extend as far as the axillary glands, which 
were removed at the time of operation. The 
disease, however, returned in eighteen months; 
and the report of the surgeon, dated October, 
1904, was as follows: " Extensive recurrence, 
not only beneath the scar and adherent to bone, 
but nodules inside the scar, and also in the skin 
of the axilla. I cannot advise further opera- 
tion with any hope of success." 

One aunt on the mother's side had died of 
cancer of the breast. 



62 CANCER 

The patient complained of great pain over 
the upper half of the chest, extending up into 
the neck and down into the arm. The pain 
was most severe toward the right of the upper 
half of the sternum, and on percussion the 
note was found to be dull at that part. The 
largest nodule, the size of an average woman's 
thumb, was situated at the lower part of the 
scar. In addition there were ten or fifteen 
small nodules adherent either to the skin or 
the ribs, and four adherent to the skin in the 
axilla. 

Thirty-one injections were given, the first 
seventeen of 5 c.c. each, the remainder of 3 
c.c. The pain was entirely relieved after the 
fourteenth injection, and was not mentioned 
afterward by the patient. The patient re- 
mained in bed on the 4th of January, 1905, 
on account of severe sciatica on both sides; 
the weather was very damp and cold at the 
time. In the end of February and beginning 
of March, the patient complained of great 
pain of a rheumatic character in both hips, 



CASES OF CARCINOMA 63 

ankles, wrists, and loins. This seemed to be 
an attack of acute neuritis of alcoholic origin. 
She rapidly became worse, there were patches 
of superficial anaesthesia, dropped wrists, and 
other symptoms of peripheral neuritis. Death 
occurred on the 12th of April, the patient having 
been very delirious for some days, calling in- 
cessantly for her old friend, beer. At the 
post mortem, the body was found to be well 
nourished. Only two nodules remained of 
the disease, the larger being the size of a hazel 
nut ; neither were adherent to skin or bone, and 
presented microscopically all the character- 
istics of ordinary scirrhus cancer. The cause 
of death is somewhat obscure. The peripheral 
neuritis could hardly have been caused by the 
arsenic, on account of the comparatively small 
amount of the drug injected; but it is much 
more likely that the beer, of which she had been 
accustomed to take very large quantities, was 
the exciting cause. At least, it was evidently 
not the cancer. 

Case XI, aet. 75, but who looked nearer 



64 CANCER 

sixty-five than seventy-five, was sent by Dr. 
Gardiner of Richmond, suffering from cancer 
of the rectum. We had told Dr. Gardiner 
that we would be glad to have any inoperable 
cases. The patient came of a long-lived family, 
and did not know if any of them had died of 
cancer. As he had been losing weight and had 
suffered from considerable discomfort in the 
rectum, with increasing difficulty in passing 
any motions, he consulted Dr. Gardiner, who 
kindly sent him on to see if we could do any- 
thing to give relief. He was seen, and the treat- 
ment begun on the 27th of July, 1903. On 
putting the finger into the rectum, the bowel was 
found to be almost closed by a large cauliflower 
mass growing from the whole of its circum- 
ference. The point of the finger could be in- 
serted into, but not through, the growth. The 
patient was unable to pass any but fluid motions, 
and it was evident that the time had arrived 
when colotomy would soon have been absolutely 
required. To have attempted to remove the 
whole of the growth, while physically possible, 



CASES OF CARCINOMA 65 

would have certainly killed the patient. In 
ten weeks, after twenty-seven injections, there 
was a marked improvement, the weight had 
increased by twenty-three pounds; the finger 
could be passed through the growth, and, by 
exerting a good deal of pressure, could just 
reach to the upper margin of the disease. 
There would have been no difficulty in getting 
three fingers through had it been more within 
reach. 

An examination was made in January, when 
it was found that half the circumference of 
the bowel was free from disease. Large solid 
motions could be passed without any difficulty. 

On the 2 2d of February, after coming in 
from a walk of four miles, the old man hurt 
his back lifting a heavy tub, and was confined 
to his bed for six weeks. He never thoroughly 
recovered from this accident, and constantly 
complained of his back. The growth continued 
to decrease, though much more slowly than it 
had done before the accident, but whether on 
account of this it is, of course, impossible to say. 



66 CANCER 

In the end of September two small patches 
of senile gangrene appeared on the heels. 
The gangrene spread, and he died on the 2 2d 
of October. The patient was not as careful 
with his bowels as he should have been, and, in 
spite of all that could be said, would not take 
sufficient laxative medicine. Nuclein had an 
extraordinary effect on him. After the first 
dose, which was given hypodermically some- 
time in the morning, the bowels began to move 
after getting into bed about ten o'clock. They 
gave no warning and everything was made in 
a mess. The quantity of faecal matter passed 
during the night was described as enough to 
fill a bucket and more. The nuclein afterwards 
always tended to move the bowels, but natu- 
rally did not have such a great effect ; but the 
patient was always afraid of what he called 
the little syringe. 

Under the circumstances the case may be 
looked on as a satisfactory one; the patient 
was saved the misery of a colotomy, and be- 
came quite well until his accident. So far 



CASES OF CARCINOMA 67 

as one could tell, his death was not in any way 
due to the cancerous growth, which steadily 
decreased in size. 

Case XII, aet. 48, was seen on the 4th of May, 
1904. For somewhere about six months the 
patient had been treated for piles. He had 
complained of increasing difficulty in passing 
his stools, and of almost constant pain in the 
pelvis, rather worse on the right side. As he 
did not improve with treatment, and was rapidly 
becoming thin and weak, he went into hospital. 
A rectal examination was made, and a few 
days afterward an inguinal colotomy was per- 
formed. Up to this time there had been no 
haemorrhage from the bowel, but while in 
hospital there were two severe attacks of bleed- 
ing from the wound. 

One aunt had died of cancer. 

We had to go several miles to see this patient 
as he was not able to be out of his room, and 
we were really overpersuaded to commence 
treatment by his wife, who was very anxious to 
try something. The case was in every way 



68 CANCER 

a most unpromising one; the man was ema- 
ciated almost to a skeleton, and the pulse was 
104, a mere thread. On passing the finger into 
the rectum, a large hard mass was felt, com- 
pletely closing the lumen of the gut, and al- 
most filling the pelvis. No opening could 
be felt in the bowel, and no water injected into 
the colotomy opening passed through, but all 
came back by the wound. The pains in the 
back and rectum were said to be very severe, 
and the appearance of the patient corroborated 
this. It was rather an interesting case to try 
what relief could be obtained, as it was impos- 
sible to say whether the pain was a genuine 
cancer pain or was due to pressure. It seemed 
probable that it was due to the cancer itself, 
as it had not changed in character, though it 
had increased very much in intensity. The 
case was a very advanced one, and had it not 
been for the pain, one would not have felt jus- 
tified in attempting anything. 

On the 5th of June, after fifteen injections, 
examination showed that the growth was smaller 



CASES OF CARCINOMA 69 

and that a distinct opening could be felt. Water 
injected into the colotomy opening flowed 
easily through the diseased part of the bowel. 
There was much less pain, and the patient 
was stronger and more able to move about. 

In the beginning of July, an attack of in- 
fluenza with a temperature of 101.5 degrees, 
and lasting a week, pulled him down, and he 
lost all the flesh he had gained in the previous 
two months. An examination was again made 
on the 8th of July, after the thirty-first injec- 
tion, with a most satisfactory result ; the growth 
instead of being smooth in outline was broken 
up and decidedly smaller, and one finger could 
be passed fairly easily into the mass of disease. 
The pulse was fuller, 90 to the minute, and 
in every respect the condition was favourable. 
The cancer pain was entirely gone, but at this 
date he began to complain of a new one of 
a screwing character in the rectum, always 
severe on the day of the injections. Treat- 
ment was stopped from the 25th of July until 
the 14th of September. During this period, 



70 CANCER 

progress was satisfactory, the colour was better, 
and the screwing pain had almost disappeared. 
The growth had again decreased in size, and 
the pulse was of good quality at 86. 

On the 1 6th of October, the forty-eighth 
injection was given. The pulse that day was 
84 and the patient looked better than he had 
done since the treatment was begun, in the 
beginning of May, five months before. Next 
day while getting out of bed, he fell, striking 
his back on the fender. He had to be lifted 
into bed, as his legs were quite useless. The 
next afternoon, on going out to give the usual 
injection, he was found to be in a state of 
collapse, and was paralysed from the waist 
downward, being unable to pass his water. He 
died the same evening. It was a most disap- 
pointing ending to what seemed to promise to 
be a very successful case, and one which, at the 
beginning, seemed about as hopeless as could 
well be imagined; still, the man was relieved 
of his pain, and had for five months con- 
tinuous improvement in health. 



CASES OF CARCINOMA yi 

Case XIII, let. 64, was seen in August, 1904. 
The history dated back eighteen months, when 
cancer of the rectum was diagnosed, followed 
by a colotomy six months later. No examina- 
tion was made by us, as the patient was much 
afraid that it would hurt him. The disease 
was said to be of an ulcerative type with con- 
traction, but no new growth. The pulse was 
96. The patient suffered much, and had got 
into the way of having morphia injected fre- 
quently. We never were able to obtain a 
correct statement of the amount taken in the 
twenty-four hours, some saying that he had five, 
and others twenty grains. There w r as neither 
emaciation nor cachexia, but the patient was 
much troubled with discharge from the rectum. 

After fourteen injections, the patient said that 
he felt better in every way ; he could sleep well, 
and the fierceness of the pain was gone. 

After the seventeenth, a quantity of pus was 
passed from the rectum. This was accom- 
panied by pain over the lower part of the ab- 
domen. 



72 CANCER 

After the thirtieth injection, the pulse was 84, 
there was very little discharge, and the pain 
was said to be less. 

In the middle of November, the patient had 
a chill, the temperature rose to 102 degrees. 
Soon afterward he became maniacal, and 
died. 

There was always a doubt about the morphia 
and how much it affected him, and the case is 
given mostly as an example of the small result 
obtained, as a rule, when there is no growth, 
but simply malignant ulceration, the only 
exception to this rule being apparently Case 
XXX, which we believe to have been a case of 
cancer of the tongue in an early stage. The 
diagnosis of such cases is, however, so uncer- 
tain that we do not claim more for it than that 
it saved the patient the loss of half his tongue. 

Case XIV, aet. 32, was seen on the 10th of Oc- 
tober, 1904. Up to the age of thirty his history 
was as follows : for the first twenty-four years 
of his life he was troubled with prolapse of the 
bowel. He had gone through various illnesses, 



CASES OF CARCINOMA 73 

including cholera, typhoid fever, dysentery, 
and malaria. For the past two years he had 
been treated for bleeding piles, and a year ago 
the doctor made an examination of the rectum 
and found no disease. For two years, however, 
there was hardly one day when there was no 
bleeding, and there was always pain. One 
day in July last there was so much bleeding 
that it flowed into his boots, and he had to 
send home for a change of all his clothes ; what 
he had on having to be burned ! In the be- 
ginning of October he saw several surgeons 
and was told that he had cancer of the bowel, 
that his expectation of life was limited to six 
months, and that the only operation which 
could be performed was colotomy. 

When seen in the evening of the ioth of 
October, the patient was in a most excited 
condition, the pulse was soft, varying from 108 
to 120 to the minute. He was very anaemic, 
there being not a trace of colour in his eyelids. 
On examining the bowel the finger came on 
an irregular mass commencing an inch and a 



74 CANCER 

half above the anus, and on pressing down- 
ward from the outside the growth was found 
to be about the size of two fists. No mucous 
membrane was to be felt. The patient had 
never had syphilis, and there was no family 
history of cancer. 

The patient slowly but steadily improved, 
his pulse came down to 94, and by the end of 
November the condition was as follows: the 
growth was decidedly smaller, and healthy mu- 
cous membrane could be felt on the posterior 
part of the rectum. The patient said, "I am 
now a clean man: formerly I was not, as 
I always had to change three times a day on 
account of the blood and mucus." The bleed- 
ing had entirely ceased, and there was scarcely 
any discharge. 

In the middle of January, 1905, attacks of 
pain came on about three hours after the in- 
jections, and on examination, the disease was 
found to have lessened by one-half, and more 
healthy mucous membrane was to be felt. 
About Easter the patient passed a bone from 



CASES OF CARCINOMA 75 

the rectum, and he then recalled that he had 
swallowed one about eight years before. A 
pain which he had often complained of under 
the ribs on the left side disappeared at this 
time. The passage of the bone did not improve 
matters in any way; indeed, about this time 
the patient was at his best. It was quite pain- 
ful to give him an injection, he was so nervous, 
and even dreamt about the needle ! 

Eventually a colotomy was performed at 
home, and the patient did not survive the opera- 
tion, but about which we did not receive any 
details. What should have been done in this 
case was that the patient should have had the 
colotomy performed at first to rest the bowel, 
and he should have been kept in bed for some 
months to give his body a thorough rest and at 
the same time allow of his being "fed up." 

Case XV, set. 68, was seen on the 30th of June, 
1906. Two years ago the patient began to 
suffer from pain in the rectum, and a year later 
a Kraske's operation was performed. The 
wound never healed, and three months after- 



76 CANCER 

ward there seems to have been some return of 
the disease. There was no history of cancer. 

Examination showed that the disease had 
returned at the anus, and on putting the finger 
into the bowel, two inches of healthy gut were 
found and then a large mass extending up into 
the left iliac fossa. There were also some 
nodules and destruction of the skin between the 
coccyx and the anus. The end of the bone 
where it had been divided could be felt through 
one of the openings in the skin. The patient 
had lost a considerable amount of flesh, and the 
pulse was 96. This was a very doubtful case. 
Injections were given three times a week. 

The pulse came quickly down to 80, but from 
the first the discharge was increased, presum- 
ably from the use of the trypsin. 

On the 2d of March the outer part did not 
look so well, but the growth in the bowel 
was smaller and there appeared to be a larger 
quantity of healthy mucous membrane. Two 
days afterward the temperature ran up to 
103 degrees, and the external parts became 



CASES OF CARCINOMA 77 

much swollen and tender. On the 20th, 
the patient said that he always felt very weak 
and limp on the days when the injections of 
trypsin were given, consequently they were dis- 
continued. There was another attack of fever 
in the end of the month. On the ioth of April, 
while the external parts were still red, irritable, 
and discharging freely, internally there was dis- 
tinctly less disease and more healthy mucous 
membrane. It was evident that it was not 
desirable to continue the treatment, as generally 
the patient was losing ground. In our expe- 
rience, it has been specially where there has 
been any ulceration, that trypsin has been very 
noticeably harmful, causing more rapid destruc- 
tion of tissue than would naturally be expected, 
and in this case we attribute the increased dis- 
charge and unfavourable condition of the ex- 
ternal parts to its use. 

Case XVI, aet. 59, was seen on the nth of 
October, 1907. After a severe attack of influ- 
enza in January last, the patient first noticed 
that she had difficulty with her bowels. For 



78 CANCER 

about a month in June and July she had taken 
iodide of potassium, which had been ordered 
without any idea that the disease was syphilitic. 
This medicine, she said, seemed only to increase 
her misery. She is unable to do much and has 
to spend the greater part of the day in bed. 
She says that she always feels miserable, and 
has a great feeling of weight and oppression at 
the bottom of her back. This was so great 
that she thought of going to hospital to beg 
for operation, so that she might either obtain 
relief or die. She is soft and flabby, and 
altogether is much out of condition. On passing 
the finger into the rectum, a thick irregular 
growth was felt surrounding the whole of the gut, 
contracting the lumen sufficiently to allow only 
of the passage of one finger. In front, the depth 
was about an inch and a half, and behind fully 
two inches. Between this and the sacrum, and 
adherent to both, there was an irregular mass the 
size of a Tangerine orange. In August, before 
a holiday, the weight was 8 st. 13 lb.; after 
the holiday 9 st. 3 lb. On the 14th of October, 



CASES OF CARCINOMA 79 

it was back to 8 st. 13 lb. ; and on the 14th of 
November it was 9 st. ij lb. The pulse was 
94. 

The injections were begun on the nth of 
October, and although they were limited in 
amount to 2 c.c, they made great bruises on the 
arms, so much so that if the patient had not felt 
quickly better it is probable that the treatment 
would not have been gone on with. On putting 
the injections into the buttocks there was much 
less trouble. 

On the 24th of the month, the patient said 
that already she felt a different creature, while 
before she did not care whether she lived or died. 

On the 29th, the patient moved into a new 
house, and although she helped in the moving, 
was not specially tired. A hard, well-formed 
motion was passed. The feeling of pressure 
over the sacrum is steadily getting less. An 
examination was made on the 14th of Novem- 
ber, one month after the commencement of the 
treatment, when the condition in front of the 
bowel was found to have completely changed. 



80 CANCER 

The finger passed more easily through the stric- 
ture, which had lost its rigidity and become 
elastic. The depth in front was about three- 
fourths of an inch, and behind the upper margin 
was more easily reached. The mass in the hol- 
low of the sacrum was smaller and more irregu- 
lar. There was no discharge and the finger 
was withdrawn without odour. The patient 
is able to be up all day and thinks nothing of 
going three or four miles, part walking and part 
by bus ; she is, as she says, a new being ! The 
pulse varies from 64 to 72. The patient was 
put on Virogen almost as soon as the treatment 
was begun. The case is given in this early 
stage as an example of the rapid improvement 
which may occur. 

Case XVII, set. 59, was seen on the 27th of 
June, 1904, suffering from malignant stricture 
of the esophagus low down. It was thought 
that some of his relations had died of cancer, 
but there was some doubt on this point. The 
disease had evidently ^ developed rapidly, as the 
first difficulty in swallowing was not noticed 



CASES OF CARCINOMA 81 

until April, and with the exception that he had 
begun to lose weight the patient had been in his 
usual state of health. By the month of June, the 
patient was rapidly being starved to death, as he 
could take only very small quantities of fluid at 
a time, and a considerable part of what he did 
take came back, sometimes apparently all of it. 
He had lost 87 lb. in weight in six months, going 
down from 14 st. 3 lb. to 8 St., the decrease 
being very much more rapid in the last month. 
He had been a heavy drinker all his life. The 
pulse w r as 98. Encouraged by Case XII, 
where an almost complete rectal obstruction 
had melted away under treatment, we advised 
the injections in the hope that the same thing 
would happen in this case, but told the friends 
that it was simply a race to see if the treatment 
would act quickly enough to open the gullet 
and thus stop the starvation. 

Ten injections were given, and the result 
was that the patient was able to drink milk 
without difficulty. He was warned to be care- 
ful, but he had little self-control, and the result 



82 CANCER 

was that he drank so freely that he became very 
sick, bringing up great masses of curd. This 
exhausted him so much that instead of improving 
he rapidly lost what little strength he had, and 
died on the 19th of July. 

We give this case simply as one of interest, 
especially when compared with cases XI and 
XII. When the treatment was begun, the man 
was much too weak to stand any operation, so 
that he had nothing to lose. The growth 
must have diminished considerably, as the pa- 
tient could not only drink freely, but there was 
room for the curd to pass back from the stomach 
through the obstruction. 

Case XVIII, aet. 57, was seen on the 2d of 
December, 1903, and gave the following interest- 
ing history of her illness. Nine years before 
she had consulted a gynaecologist attached 
to one of the general hospitals on account of 
menorrhagia. On examination it was found that 
she had a fibroid tumour of the uterus. As the 
symptoms were not at all severe and as the 
patient was forty-eight years of age, she was 



CASES OF CARCINOMA 83 

advised, very properly, to have nothing done, 
but to trust to the natural cure at the menopause. 
Menstruation ceased soon after the age of fifty, 
and the tumour became smaller, though how 
much smaller the patient could not say, as she 
was not examined again. In October, 1902, 
the lady consulted the same gynaecologist on 
account of discomfort in the pelvis, pain when 
the bowels moved, and some leucorrhoea. He 
found that she was suffering from cancer of the 
neck of the womb, and said that the disease was 
so far advanced that nothing could be done. 
The patient was not satisfied with this advice 
and had the growth scraped, then tried "high 
frequency, " and also had a course of salicylate 
of soda. She thought that the scraping and 
high frequency did her good, and that the sali- 
cylate did her harm. 

When she was seen in the beginning of De- 
cember, 1903, she looked very ill, she was yellow, 
anaemic, and very much emaciated. The pulse 
was 120. On vaginal examination, the small 
remains of the cervix were felt, into which the 



84 CANCER 

tip of the finger could be passed. Bi-manually 
the uterus was found to almost entirely fill the 
pelvis. The whole mass was much fixed, and 
the growth came very near on to the base of the 
bladder. 

The patient was advised that the case was in 
every way an unfavourable one, and that it did 
not seem to be one where even any temporary 
improvement could be expected to be gained by 
treatment, that no treatment short of complete 
removal could hope to cure, and that this was 
not feasible on account of the general debility 
and the local difficulties. The patient was 
desperate to try anything, as she felt so ill and 
suffered so much, especially when the bowels 
moved. Eventually she was told that if she 
cared to come back, we might in the meantime 
change our decision. She came back in three 
days, and it was then suggested that a course of 
about thirty injections might be tried, and then 
if the general health and the local fixing improved 
sufficiently, the operation of total removal of 
the uterus would be performed. In less than a 



CASES OF CARCINOMA 85 

month the pulse had come down to 96, and the 
bowels could be relieved without pain. 

By the end of January, the pulse had fallen 
to from 82 to 86. The growth was not so fixed, 
but the thickening toward the base of the blad- 
der had not entirely disappeared. Though the 
patient had not gained a very great deal of 
strength, it seemed that she would be able to 
withstand the operation if it could be per- 
formed within an hour, and it was agreed that 
if, on opening the abdomen, this was found to 
be impossible that it would be abandoned. The 
operation was performed on the 29th of January, 
1904. The tumour almost filled the pelvis, 
and there was much adherent intestine, the lower 
part was thin and friable and tore off. As it 
would have prolonged the operation too much 
to take out the cervix then, we were satisfied to 
stop the bleeding, close the wound, and leave 
the cervix to be removed at a second operation. 

On cutting open the specimen, the whole of 
the enlarged cavity was found to be filled with 
cancerous growth. The cervix was removed 



86 CANCER 

by the vaginal route twelve days later. In front 
it was impossible to be at all certain that we 
were quite clear of the disease, on account of the 
closeness of the bladder. 

After the operation, the patient could not be 
persuaded to keep up the injections, and she 
only had nine. This was a mistake. Strength 
did not return well, and the patient never really 
got strong, though she was able to drive out. 
Toward the end of June there was a suspicion 
that there was a small leak from the bladder. In 
the month of August, she went to the country, 
and as there was no conveyance at the country 
station had to walk, what was for her, quite a 
long way, and next day there was some haemor- 
rhage. She was again seen toward the end of 
September. On the 15th of October a fistulous 
opening into the bladder was found and a month 
later most of the water was passed through this 
opening. She died on the 24th of January, 1905, 
and it is interesting to note that the pulse varied 
from 72 to 84 for the last three months of her life. 

A case of great interest is the best that one can 



CASES OF CARCINOMA 87 

say. It is doubtful if it is wise to try anything 
for such a very advanced case of disease, as the 
patient has to go through so much and the 
chance of permanent recovery is so small. Cer- 
tainly one cannot believe that the operation, 
which was performed in the end of January, 
could have possibly been successful two months 
earlier when the pulse was 1 20 ; but in surgery 
what is possible and what is really advisable in 
the interest of the patient do not always mean 
the same thing. 

Case XIX, aet. 55, was first seen in June, 1904. 
At that time she had hardly begun to recover 
from what was described as a very bad haemor- 
rhage from the uterus, and the history obtained 
was as follows: she had gone through the 
menopause without trouble at the age of forty- 
seven. One year ago she began to have 
haemorrhages from the vagina. At first they 
were slight, but as they quickly increased in 
amount she sought advice. Cancer of the uterus 
was diagnosed. She was sent into hospital and 
an attempt was made to remove that organ. 



88 CANCER 

This was found to be impossible, and the surgeon 
appears, from what one can gather, — and inci- 
dentally it seems to be a pity that patients in hos- 
pital seem usually to be told little or nothing, 
— to have contented himself with scraping. At 
intervals of somewhere about two months, there 
was a haemorrhage of an alarming nature, and 
when the patient was seen shortly after one of 
these, she was so weak and anaemic that it was 
impossible for her to come to us, and it was 
equally impossible for us to spare the time to 
go to her. 

There was a little history of cancer in the fam- 
ily, as one cousin had died of the disease. 

On examination it was found that the cervix 
had disappeared, the finger entering a cavity 
with a hard irregular edge; the uterus itself 
was fixed, and deposit was found in both broad 
ligaments. The patient was not wasted, though 
she said that she had lost flesh. 

In December of the same year, happening to 
be in the neighbourhood, and having received 
several letters asking if nothing could be done 



CASES OF CARCINOMA 89 

to give her help and relieve her pain, she was 
seen again. There had not been any haemor- 
rhage for over a month, and the general condition 
was much improved. Locally, the ulceration 
had increased and the fixing and size of the 
uterus were greater. On looking through a 
speculum, a large irregular opening was seen 
at the top of the vagina, extending far backward, 
and surrounded by a narrow red ring of tissue, 
but there was no appearance that there had ever 
been a cervix, so entirely was it destroyed . There 
was a constant, profuse, and foetid discharge, and 
in spite of attention to cleanliness, the whole 
house was disagreeable from the odour. She 
had lost more flesh and suffered much from 
pain in the back, and also in front over the pubes. 
The pulse was fair at 90. 

In a case of this kind one is apt to be over- 
persuaded, and it was agreed to give the injec- 
tions to relieve the pain, though the patient lived 
at a most inconvenient distance, and, like the 
great majority of the cases, was not in a position 
to offer any return for our services. 



90 CANCER 

The case was rather an obstinate one, and the 
pain was not relieved until six injections had been 
given, and by that time she had improved so 
much that she was able to come to town for 
treatment. After double that number, there 
was a very decided lessening in the amount of 
discharge, and even in the patient's room little 
odour was to be detected, the offensiveness had 
so much decreased. The amount of improve- 
ment in this direction will be realised when it is 
mentioned that, instead of using many diapers 
in the day, a little cotton-wool changed once 
was sufficient ! There was a backache when the 
patient was tired, otherwise she was quite free 
from pain. An examination was made at the 
end of February after thirty injections had been 
given, and some decided improvement was 
found. There was a distinct cervix and the 
opening into the uterus was smaller. There 
was a great deal of redundant mucous mem- 
brane. The following day her usual medical 
attendant made an examination, and unfortu- 
nately was evidently anxious to be very thorough. 



CASES OF CARCINOMA 91 

He hurt so much that the patient screamed with 
the pain. She began to bleed shortly afterward, 
and the next day there was a severe haemorrhage, 
the first for nearly four months. 

Ten days later she was again able to come to 
town, but looked very shaky, and complained 
of some return of the pain and increase in the 
amount of discharge. The pulse was 76. The 
injections were recommenced on the nth of 
April after an interval of six weeks. 

Toward the end of May, an examination with 
the speculum showed a cervix of almost normal 
appearance except toward the back, where it 
looked as if it were a little eaten out. The uterus 
felt smaller and looser, and there was less hard- 
ness to be felt in the broad ligaments. As regards 
her general appearance, she looked a well woman. 

Sixty injections had been given by the end of 
July, but in the months of August and Septem- 
ber there were three severe haemorrhages. The 
interior of the uterus was then thoroughly de- 
stroyed with caustic potash. There was quite 
a good deal of bleeding after the operation, but 



92 CANCER 

by the beginning of November the patient was 
better, and, injections being resumed, she com- 
menced to improve quickly. Quite at the end 
of December trypsin was injected in addition. 
She continued to improve until the middle of 
February when she began to fail rapidly, and 
died, apparently of septic absorption, on the 
1 2th of March, 1906. 

A post-mortem examination revealed a pelvis 
full of putrid pus, with a soft, friable shell of a 
uterus, and little disease or thickening in the 
broad ligaments. There was an inch of fat on 
the abdominal wall and proportionally all over 
the body, a very much better general condition 
than when the treatment was begun some fifteen 
months before. Besides, the patient was re- 
lieved of her pain, and was able to live like other 
people most of the time, instead of being a 
misery to herself and to others from the offen- 
siveness of the discharge. 

Case XX, aet. 59, was seen on the 21st of April, 
1905. She complained of agonising pain and 
loss of strength. Her history was as follows: 



CASES OF CARCINOMA 93 

she had married late in life and had never been 
pregnant. She passed through the menopause 
without trouble at the age of forty-eight, and, 
indeed, until she began to feel unwell eighteen 
months ago, had never been ill. 

There was no case of cancer among any of 
her relations. The first symptom she noticed 
of her present illness was a vaginal discharge, 
soon followed by pain in the back, and she was 
treated for ulceration of the womb for six months. 
Getting no better, she went to a hospital for 
women, and was there scraped. When she left 
hospital, one of the medical staff recommended 
her to consult a doctor in the north of London 
who was supposed to be able to cure cancer, 
but after a six months' course of pills and fluid 
medicine was not any better. At the Middlesex 
Hospital the case was considered a hopeless one 
and nothing was recommended. For three 
weeks she had been taking an infusion of violet 
leaves without benefit. It is wonderful what a 
hold this treatment has obtained without, so far 
as we know, a single authentic case of recovery. 



94 CANCER 

The patient was markedly cachectic, was 
thin, and the pulse was ioo. On vaginal 
examination, it was found that the cervix had 
entirely disappeared, there being simply a 
rough ulcerated opening in its place. The 
whole of the posterior fornix was included in this 
ulceration. The uterus was big and fixed by 
a large amount of infiltration in the broad liga- 
ments. Altogether fifty injections were given 
of 3 c.c. each, treatment only being undertaken 
to relieve the agonising pain. After five injec- 
tions the pulse slowed down to between 72 and 
80 and remained at this till shortly before 
the end. The pain was relieved at once and 
there was not a trace of it after the eleventh 
injection. 

On the 19th of May there was thrombosis 
of the right external saphenous vein which 
cleared up by the 25th of the month. In July 
the patient had slight uterine pain after being 
shaken in a bath chair. In the beginning 
of August a sharp attack of diarrhoea pulled 
her down and the injections were discontinued. 



CASES OF CARCINOMA 95 

The patient died peacefully on the 14th of 
September, and almost the last words she was 
able to utter were to express her gratitude 
for the six months' relief from pain obtained 
from the injections. 

Case XXI, act. 56, but looks fully ten years 
older, was seen on the 2 2d of September, 
1906. She gave the following history: for 
about one year she had not felt well and for 
some months suffered from constant headache. 
She went to New York in April and then noticed 
that her abdomen was getting larger, and two 
months afterward she consulted a London 
doctor who diagnosed cancer of the uterus. 
The following month the abdomen was opened 
and part of the growth was removed, at least 
this was what the patient was told. 

There was no family history of cancer. 

The patient was weak, anaemic, specially 
thin, and the pulse was 96. The abdomen 
was distended by some ascitic fluid and a 
mass filling the left side, extending well across 
the middle line and reaching to within two 



96 CANCER 

inches of the umbilicus. The cervix was 
large, swollen, and lacerated, but there was no 
ulceration. A hard growth in the posterior 
fornix was continuous with the abdominal 
tumour. 

This was quite a hopeless case, but as the 
patient was very anxious to be made well 
enough to get home to the West Indies in 
November she was given sixteen injections of 
3 c.c. The tumour diminished decidedly, but 
on the 9th of October there were evident 
signs that the heart was failing, shown by 
swelling of the feet with increasing pulse rate, 
and the patient died on the 23d of October. 

This case may be looked on as a complete 
failure, the reduction in size being of interest, 
but of no practical importance. It was too 
late and had it not been for the great desire 
of the patient to be able to go home, nothing 
would have been attempted. This would. evi- 
dently have been the proper course to have 
pursued under ordinary circumstances. 

Case XXII, aet 50, was seen on the 13th of 



CASES OF CARCINOMA 97 

January, 1904. She first noticed that she was 
jaundiced toward the end of May, 1903, and 
on consulting a doctor was told that she had 
cancer of the liver. Since then she has steadily 
lost ground in e and in January- the 

woman was emaciated, weighing 7 st. 8 lb., 
the skin and conjunctivae were deeply jaun- 
diced, the stools were clay-coloured, and the 
mine complained of 

rapidly progressing weakness, of severe but 
not constant pair, in the and of the most 

irritation of the skin. She stated that 
her appearance was so that people 

jeered at her if she : of Ic ::s. and 

the policemen smiled at the sight of her. She 
was too weak tc go out alone a: this ::me. 

On examining the abdomen the liver - 
found to extend from the fourth rib to level 
with the crest of the ilium, and there was an 
irrezular mass of stony hardness in the position 
of the gall bladder. 

There was no known family history of cancer. 

The patient had been a hard-working woman 



98 CANCER 

all her life, and though her husband was a 
heavy drinker she was abstemious. This case 
was undertaken with really very little expec- 
tation of doing the patient good, but more as 
an experiment to see how a damaged liver 
would be affected by the injections. The 
dose was never more than half what we usually 
give. 

On the 13th of January the first injection 
was given. On that day the pulse was 80; 
VII min. of a 5 per cent of nuclein were also 
administered hypodermically. 

14th. The patient felt faint after the first 
injection. The pulse had fallen to 72. 

1 6th. Third injection, no nuclein, patient 
looks better, but the irritation of the skin is 
very bad. 

1 8th. Fourth injection, there was no pain 
yesterday, and there was freedom from irrita- 
tion the day before. 

19th. Fifth injection and nuclein. 

21st. Sixth injection, feels better and has no 
pain, but is sleepless. 



CASES OF CARCINOMA 99 

26th. Patient has had a bad attack of diar- 
rhoea, probably caused by the nuclcin, which 
was not continued. 

28th. Tenth injection, is sleeping better and 
there is less irritation of the skin. 

7th of February. Fifteenth injection, the 
liver dulness now extends only from the sixth 
rib to midway between the costal margin and 
the umbilicus. 

13th. Nineteenth injection, there is much 
less irritation. 

25th. Twenty-ninth injection, the conjunc- 
tivae are not so yellow and the urine is paler. 

5th of March. Thirty-sixth injection, for the 
first time since September of last year the stools 
were slightly coloured. 

14th. Forty-third injection, the patient feels 
well and looks much less yellow. 

15th. To-day the stools are clay-coloured 
and the urine dark. This is perhaps due to 
catarrh, as the patient has a bad cold. 

19th. Bile is again flowing into the intestines 
and the faeces have become brown in colour. 

L6FC. 



ioo CANCER 

7th of April. Sixty-third injection, the liver 
itself is almost of normal size with the exception 
of the enlargement in the position of the gall 
bladder, which still projects markedly. The 
weight is 7 st. 7 lb., a loss of one pound only 
since the treatment was begun, nearly three 
months ago. 

20th of May. Eighty-second injection, the 
patient is apparently well and the treatment is 
to be discontinued meanwhile. 

5th of September. The patient after having 
been well is troubled with the irritation of the 
skin. Injections were recommenced and by 
the 1st of November sixteen had been given. 
In other respects the patient has little to com- 
plain of. 

13th of March, 1905. There is no note of 
interest until this date, the patient having kept 
well with occasional slight attacks of skin irri- 
tation. The weight to-day is 7 st. 9 lb. There 
is a little jaundice accompanied by light- 
coloured stools. 

24th. The patient has not been at all well, 



CASES OF CARCINOMA 101 

and on examining the liver to-day it was found 
to be enlarged and smooth like an ordinary 
congested one, and reached as far down as the 
umbilicus. The pulse was 66. 

29th of May. Nine injections have been given 
since the last note. The patient seems to be 
quite well and is putting on flesh. The liver 
can barely be felt below the costal margin. 

9th of January, 1906. The liver is two inches 
below the edge of the ribs. There has been 
some return of the irritation. 

Twenty-nine injections were given between 
the 26th of January and the 6th of April, but 
the patient steadily lost weight, which had got 
up to 8 st. 9 lb. in the previous year. It now 
fell to 7 st. 1 lb. 

The patient had a return of the jaundice and 
continued to lose weight until September, 
when injections, to the number of fourteen, 
were given. Although in July the woman 
looked very ill, by November she was putting 
on weight and was able to do her housework. 

One hundred and fifty-one injections, ex- 



102 CANCER 

eluding those consisting of nuclein, have been 
given in a little over thirty months ! 

In October, all the glands on the right side 
of the neck became inflamed and those in the 
anterior triangle suppurated. On the left side 
they became slightly enlarged. The abscess 
on the right side was opened and drained on 
the 20th of the month and continued to dis- 
charge until the end of November. 

In February, 1907, the patient was not so 
well, and the injections were begun on the fifth, 
and were continued thrice weekly until the 
2 2d of April, when an abscess in the arm, due 
to the injections, had to be opened. In May, 
the injections were given twice a week, and in 
June once a week. Toward the end of the 
month a large abscess formed in the right 
breast, and the wound in the neck opened. 
In the month of August the patient went to 
the Middlesex Hospital on account of the 
suppurating breast and neck, and because we 
were away. 

On the 28th of October the patient was well 



CASES OF CARCINOMA 103 

and able to do her washing! There was no 
skin irritation, though the stools were rather 
light. The urine was a good colour but for 
the first time contained some sugar. The 
left lobe of the liver was slightly enlarged, 
otherwise the organ seemed to be healthy. 

Case XXIII, aet. 50, was seen on the 24th of 
March, 1904. For some months the patient 
said that she had noticed what she called a nob 
in the right side of the abdomen. Eight weeks 
ago it was noticed that she was jaundiced and 
about the same time the patient observed that 
the stools were clay-coloured. The pulse was 
84, and she complained of intolerable irrita- 
tion of the skin, the whole of her body and limbs 
being covered with marks of her scratching. 
The patient was very deeply jaundiced, and the 
liver measured 13 inches from above down- 
ward. There was also a little free fluid in 
the peritoneal cavity. 

The irritation became bearable after five 
injections and never got very bad again. The 
liver rapidly became reduced in size, coming 



104 CANCER 

down to under 10 inches instead of 13, but 
no bile appeared. Toward the end of July 
ascitic fluid began to increase with great rapid- 
ity and it had to be drawn off. After its re- 
moval, the liver could be felt exactly like an 
ordinary hob-nailed organ. 

We are of the opinion that the injections 
were much too strong, being of the usual 
strength, and that it would have been better 
to have given them weaker and not so often, 
as the liver seemed to be reduced in size much 
too quickly. After the tapping, bile flowed 
freely into the intestines, but it was too late 
to do good. 

Case XXIV, aet. 65, a coachman, was seen 
on the 28th of May, 1904. His history was 
that ten months before he began to feel tired 
and languid, and three months ago the liver 
was found to be enlarged, cancer being diag- 
nosed. There was no pain, but deep jaundice 
and enormous oedema of the legs, thighs, 
scrotum, penis, and abdominal w r all. The liver 
extended far below the umbilicus and almost 



CASES OF CARCINOMA 105 

filled the abdomen. He was very breathless 
and the pulse was 96. 

This was evidently not a suitable case, but 
as we had declined to treat a relation of the 
man's mistress, who died within six weeks and 
justified our refusal, we hardly cared to decline 
a second case. 

After the third injection the patient was less 
breathless and could digest his food better. 

After the sixth the legs were softer, he could 
button his waistcoat, and his boots felt too big. 

After the eleventh it was noticed that while 
his legs were decidedly softer and smaller, the 
abdomen was beginning to fill with fluid. 

On the 23d of June he was tapped, 78 ounces 
being removed, but the size of the abdomen did 
not seem to be lessened. He died a week 
afterward of a low form of septicaemia. 

This case is one which might in all proba- 
bility have improved as much under other forms 
of treatment, and the injections most likely 
acted more as a tonic than in any other way. 

Case XXV, aet. 67, was seen with Dr. Pearson 



106 CANCER 

in April, 1903, and gave the following history 
of her illness. She had noticed a swelling in 
the left hypochondriac region nearly a year 
before and some short time afterward had to 
give up her calling of a sick nurse, on account 
of increasing debility. She was thin enough 
to be described as a bag of bones, had well- 
marked cancerous cachexia with great anaemia, 
and was very constipated. A large tumour 
distended the abdomen, filling the whole of 
the left side and extending fully four inches 
across the middle line. Seventeen injections 
were given. The tumour rapidly decreased 
in size, but the patient did not feel better and 
treatment had to be discontinued. The old 
lady died in September, and Dr. Pearson wrote : 
"The growth had very markedly diminished 
in size, and though she was very much more 
emaciated, no sign of it could be seen ex- 
ternally, the abdomen being perfectly flat. 
The growth proved to have primarily arisen, 
I should surmise, in the descending colon, 
which was adherent to the parietal peritoneum. 



CASES OF CARCINOMA 107 

It had undergone considerable degeneration, 
and was very friable. I cannot express to 
you how surprised I was to find the bulk of it 
so much diminished. The lumen of the gut 
was perfectly patent." The microscopic re- 
port said, "The larger section (colon) is infil- 
trated with a degenerated colloid carcinoma, 
which is probably of the columnar-celled type, 
though its cells are now much altered." 

Case XXVI, aet. 52, was seen in August, 
1907. The disease was evidently acute, as the 
patient had been apparently quite well in May. 
In that month she began to vomit her food 
almost immediately after it was taken, and 
the friends began to notice that she was getting 
rapidly thinner. There was no pain, but 
great acidity when she vomited. The pulse 
was good. 

On examining the abdomen, an exception- 
ally large mass was felt in the epigastric and 
left hypochondriac regions, the greater part of 
the stomach being evidently involved in the 
disease. 



108 CANCER 

Treatment was advised and was carefully 
carried out by the patient's doctor, but as there 
was no improvement after fifteen injections, it 
was thought advisable not to continue. 

This is an example of the difficulty of treat- 
ing successfully cases where a vital organ is 
attacked. 

Case XXVII, aet. 54, recommended by a lady 
who knew of case II, was seen on the 3d of 
April, 1907. Some months before, a sister had 
been operated on in the North for cancer in the 
rectum, the operation ending in an exploratory 
one only. It was proposed that we should see 
if this sister was a suitable one for treatment ; 
but the surgeon persuaded the friends that 
nothing could do any good, though he knew 
nothing whatever about the treatment suggested, 
and we were willing that he should be told 
the exact nature of the remedy if we consid- 
ered it a suitable case ! 

For about two years the patient had suffered 
from catarrh of the stomach and constipation, 
culminating in an attack of intestinal obstruc- 



CASES OF CARCINOMA 109 

tion in March. The abdomen was opened 
by a well-known surgeon, who found a mass of 
malignant disease involving the transverse and 
ascending colons, the small intestine, mesentery 
and stomach, with glandular infection behind. 
Removal of the disease was evidently impossible 
and the bowel was short-circuited to relieve the 
obstruction. Three weeks afterward, on the 3d 
of April, the patient was said to have made no 
progress; she was still in bed, was a bad colour, 
looking typically cachectic, and was anaemic 
and very thin, but did not know how much 
weight she had lost. The pulse was shabby 
and small and jumped up from 72 to 100 on 
slight exertion and did not come down quickly. 
She felt weak and ill, had not so much pain as 
discomfort and a great feeling of misery. The 
scar was very red and there was a tender spot 
in the position of the pylorus. She was much 
troubled with flatulence and slept badly, three 
to four hours in the night being considered a fair 
night's rest. 
The first injection of 2 c.c. of the weaker 



no CANCER 

strength was given on the 13th of April, and the 
thirteenth on the 4th of May. At first the injec- 
tions seemed to stir up the flatulence and to cause 
" flushings." Now there is some improvement 
she is not so uncomfortable and thinks that she 
has put on some flesh ; weight in her clothes 7 st. 

7 lb. The abdominal belt does not fit as the 
abdomen has become smaller. On the 10th 
of May she went out for her first drive, and on 
the 26th it was found that she had gained two 
pounds in weight. The thirtieth injection was 
given on the 9th of June, the result so far being 
that the patient looked better, had less indiges- 
tion, and was gaining a little weight. On exam- 
ining the abdomen no definite growth could be 
felt, but there was decided resistance over the 
whole of the upper part, with tenderness on pres- 
sure as before. The lady returned to town on 
the 9th of July. The weight had gone up to 

8 st. 7! lb., and the pulse was fuller. There 
was still the feeling of resistance, but the ten- 
derness on pressure was absent. Sleep was much 
improved, usually six hours every night, and on 



CASES OF CARCINOMA in 

one occasion she had walked a mile with two 
rests. The injections again stirred up the flatu- 
lence and flushings. On the 25th the weight 
was 8 st. 11 lb. On the 7th of August the 
forty-fifth injection was given and the patient 
went to the country for a month. 

On the 6th of September the weight was 9 st. 
2 lb., weighed in the same clothes every time. 
While she was away she got a chill and was very 
miserable for a couple of days. There is to-day 
less flatulence, and the feeling of resistance is 
quite gone, and, on deep pressure, a mass the 
size of two adult thumbs can be felt where the 
tenderness has been. The scar is beginning to 
fade, a sure sign of returning health. She has 
walked as far as a mile and three-quarters. The 
husband asked the doctor who had been present 
at the operation, and who had attended until the 
treatment was begun, in what condition he would 
expect his wife to be, and the answer was that 
she should be breaking up by now. This third 
course of injections did not set up the flatulence. 
On the 30th of November the patient continued 



112 CANCER 

to be in good health, without any signs of the 
disease lighting up. 

Case XXVIII, aet. 64, was seen on the 13th 
of February, 1905. The patient, a rather stout 
woman, comes of a long-lived family with no 
history of cancer. 

Six years ago she had her first operation for 
something internal; the second was performed 
eight months ago, and the third, an unfinished 
one, four months since. Up to within from 
eight to ten weeks there was no pain, then it 
began to come occasionally. For the last three 
weeks it has been very bad indeed, — torture the 
lady called it, and her daughter said the mother 
cried most of the day on account of it. The 
patient is almost an invalid and the pulse is 100. 

On examination there is a hard mass found 
in the left groin, measuring about four inches 
in every direction. It is not defined and the 
skin covering it is red and inflamed. 

Within half an hour of the first injection the 
pain had disappeared ! The patient improved 
for a time and was able to walk without her 



CASES OF CARCINOMA 113 

stick, but this improvement was only of a tem- 
porary nature and the patient did not live long, 
though fortunately the pain was hardly ever 
complained of and it never appeared at all 
severely. 

We are inclined to think that the growth 
diminished too quickly at first, and that it would 
have been better if the reduction in the size had 
been slower. Patients do not seem to do so 
well when a growth is very quickly reduced in 
size. 

Case XXIX, aet. 53, a widow, was seen in 
June, 1903. The history she gave was as fol- 
lows: in the beginning of 1902 she con- 
sulted a well-known surgeon specially identified 
with the surgery of the bladder on account of 
frequent desire to pass water with some pain, 
and the appearance of mucus and frequently 
blood in the water. The amount of blood passed 
varied greatly, there might be none for some days 
and then there would be what the patient de- 
scribed as a large loss. The bladder was opened 
from above and something was removed. 



ii 4 CANCER 

Before leaving the Surgical Home the patient 
asked if the growth was of a cancerous nature, 
and was told that she need not be anxious, 
and that the symptoms would never recur. 
Within three months of the operation all the 
symptoms had returned as badly as before. 
This was the history up to the time we saw her. 
She was evidently then beginning to "go down 
the hill" — she was soft and flabby, and the 
pulse was 98 with little strength. One aunt and 
two cousins had died of cancer. On making a 
digital examination from the vagina a hard swell- 
ing was felt situated on the left side, apparently 
in the bladder wall. It measured roughly one 
and a half inches in length by one in breadth. 
On using the electric light in the bladder, the 
surface of the swelling, an oval, perhaps one 
by half an inch, was seen to present the typical 
appearance of a case of cancer; there was no 
polypus, and it did not have the appearance of 
a simple papilloma. The patient was asked to 
see the surgeon who had operated, but would not 
consent to do so. As this was mostly for our 



CASES OF CARCINOMA 115 

own satisfaction, and as the growth could not 
have been removed without making a large open- 
ing into the vagina, and even then complete 
removal would have been doubtful, the consul- 
tation was not pressed, and injections of iodipin 
and arseniate of iron were begun. After a fort- 
night, during which time there was no haemor- 
rhage, an attack came on but was not so severe 
as usual. Improvement was then steady until 
September, when the patient lost a large quan- 
tity of blood. The injections were recommenced 
after the holidays and the patient very steadily 
improved, both locally and in general health. 

Altogether over one hundred injections were 
given, with the result that the growth in the 
bladder wall became reduced until it felt no 
larger than a split pea, and on electrical illumi- 
nation presented the appearance of a small 
patch of congestion. The symptoms did not 
entirely disappear, but on the whole the patient 
was able to live like other people. Late in the 
summer of 1906 she was not so well, and her 
friends persuaded her to see another bladder 



n6 CANCER 

surgeon. What the condition was at this time 
we do not know, as we had not made an exami- 
nation for a long time. The bladder was again 
opened and something was removed. The same 
prognosis was given as before the first operation, 
but the symptoms returned within a few weeks. 
We have heard that the patient is still fairly 
well. It seems probable that there was a malig- 
nant base in the bladder wall with papillomatous 
projections, and that these projections were 
removed at the two operations, as no expert 
operator would have attempted to do anything to 
this case as it was in June, 1903. It is now con- 
siderably more than four years since the treat- 
ment was begun ; and it may fairly be claimed 
that this was a case of malignant disease, in 
spite of the diagnosis of the two surgeons, 
more especially as their prognosis was completely 
wrong, and also that the patient has lived for 
some years longer than she would have done 
without the treatment. In June, 1903, the ut- 
most estimate of life would have been one year. 
Case XXX, aet. 37, was first seen on the 15th of 



CASES OF CARCINOMA 117 

October, 1903, on account of an ulcer on the 
right side of the tongue. He said that when 
he was a boy at school he was much troubled by 
small ulcerations on his tongue, and the school- 
master was in the habit of touching them with a 
stick of caustic. As near as possible he fixed 
the time since the ulceration commenced at 
two months. The ulceration was continuously 
painful and the pain was increased when eating 
or drinking. It was hard, measured about an 
inch and a quarter in length and one- quarter of 
an inch at its widest part. The ulceration had 
not the appearance of a syphilitic one, and the 
patient said that he had not had the disease. 
One brother died in the Cancer Hospital, but 
apparently not of cancer, and there was no 
family history of malignant disease. The glands 
all over the body were carefully examined, but 
none were found to be enlarged. Five grains 
of iodide of potassium and one-sixteenth grain of 
perchloride of mercury were given three times 
a day for a month, with at first great improve- 
ment in the appearance and size of the ulcera- 



n8 CANCER 

tion, though the pain was not in any way 
relieved. The improvement soon stopped and 
the ulceration then commenced to spread 
rapidly. 

The injections were from one cause and 
another not commenced until two months after 
the patient was first seen. By that time there 
seemed to be no doubt about the malignancy 
of the disease. Had the generally recognised 
surgical practice been followed, the removal of 
half the tongue would have been the proper and 
only course of treatment, as the disease had not 
yielded to anti-syphilitic remedies. 

The injections had a peculiar effect as they 
set up cramp, not only in the arm into which the 
injection was given, but also, though in a lesser 
degree, all over the body. 

The ulcer had begun to get smaller, and the 
pain had been reduced after the eighth injec- 
tion, and it had entirely healed by the seven- 
teenth. Twenty-one were given in all. 

In October, 1905, the patient had a throm- 
bosis in both legs, due to varicose veins. 



CASES OF CARCINOMA 119 

September, 1907. For the past two years the 
legs have given an immense amount of trouble, 
and there have been varicose ulcers almost con- 
stantly. Bandaging was said to give too much 
pain to be continued for any length of time, 
although on several occasions when elastic ban- 
dages were kept on there was decided improve- 
ment. Every form of treatment imaginable 
was tried, — anti-syphilitic, anti-tubercular, anti- 
rheumatic, etc. Finally, injections of iodipin 
alone were tried and proper bandaging insisted 
on. This was followed by rapid improvement, 
but the bandaging was soon neglected and re- 
lapse followed in spite of the injections of iodi- 
pin. At last the patient realised that he must 
persevere with the bandaging and put up with 
the pain for the time. The result has been most 
satisfactory, the mechanical support evidently 
being all that was required. 

Case XXXI, aet. 40, complained first of a sore 
throat in April, 1904. He consulted a doctor, 
who told him that there was a growth, and two 
operations were performed without an anaes- 



120 CANCER 

thetic, but the patient was told neither what was 
the matter nor what had been done. 

In the month of December he was shown at 
the laryngological society before over twenty of 
the Fellows. It was unanimously agreed that 
the case was one of epithelioma, that it could 
not be removed by operation, and that in all 
probability the sufferings of the patient would 
come to an end within six weeks or so. 

He was seen on the 30th of January, 1905, 
and said that there was no cancer among his 
relations, but that his mother had died of 
dropsy. This might, of course, have been due 
to malignant disease, and is a good example of 
what we have said about the difficulty of being 
sure of the family history of most patients. 
He looked wasted and said that he had lost a 
considerable amount of w T eight, and he com- 
plained of great pain in the left cheek and ear, 
with stiffness of the jaw and inability to swallow 
solid food. He said that he had not been able 
to swallow anything solid for over six months. 
His taste for smoking had also entirely left him. 



CASES OF CARCINOMA 121 

The breath was very offensive. The pulse was 
96, small and thready. 

On looking into the mouth it was seen that 
the disease had covered the whole of both the 
soft and hard palates, touching the teeth all 
round. It extended on to both tonsils, and, pass- 
ing over the teeth on the left side, was attached 
to the outer side of the jaw and the cheek. 
Numerous glands could both be seen and felt 
on both sides of the neck. The poor man was 
living in the greatest misery, he suffered severely, 
and in all our experience we have never met 
with any one who suffered so much and was 
at the same time so patient. His strength was 
going, both from the ravages of the disease and 
from the want of power either to masticate or to 
swallow proper food. It was an interesting case 
to see if the pain could be relieved in such an 
advanced state of disease, and at the same time 
to watch for any general improvement and in- 
crease in the expectation of life. The injections 
were given almost daily and after the third there 
began to be improvement both in the pain and 



122 CANCER 

in the offensiveness of the discharge. When he 
had had seven injections, he said that the jaw 
felt looser, that there was no pain, and that he 
could rest his left cheek on the pillow — a thing he 
had not been able to do for months. The odour 
of the discharge had much lessened, and he also 
found that his breathing was easier. He was 
able to swallow solid food after the twelfth in- 
jection, and said that no one could believe the 
pleasure he derived from eating a chop after 
six months of slops. His taste for smoking 
had also come back. The pulse had improved 
in quality and was down to 70. A healthy 
piece of palate was exposed behind the front 
teeth and there was less disease at the back, as 
was shown by the molar teeth being exposed. 
By the beginning of March his ability to swallow 
had so much improved that he could get down 
a pill without water. Toward the end of the 
month there was much toothache and two molars 
had to be removed; with both there was sup- 
puration at the roots. An abscess also formed 
in the cheek, and, pointing externally, had to 



CASES OF CARCINOMA 123 

be opened through the skin. After a fortnight 
in the country, without treatment, the cheek 
looked more swollen, though in other respects 
the man felt well. Another tooth had to be 
extracted. Until the end of May he felt very 
comfortable, the disease on the palate was slowly 
decreasing, while that on the jaw and cheek 
remained stationary. Two loose pieces of the 
growth had to be removed, as they were falling 
back into the throat. On the 30th of the month, 
injections of trypsin were begun and were given 
every alternate day. Apparently their effect 
was not good, as the disease had started to in- 
crease by the middle of June, opening up the 
scar in the cheek and projecting through it. 

On the 5th of July treatment with X-rays 
was begun and quickly healed the opening in 
the cheek. In October the ulceration again 
broke through the skin and continued to 
increase. In spite of this the patient kept 
wonderfully well and was able to eat any kind of 
solid food until the middle of January when he 
began to fail in every way, and he died on the 



124 CANCER 

7 th of February, a year after the treatment 
was begun. 

This was one of the cases where trypsin seemed 
to be very harmful ; but though it undoubtedly 
did harm and caused the disease to grow more 
quickly than it had been doing, it cannot be said 
that permanent recovery was prevented by its 
use. There was evidently too much disease to 
be cured, but the treatment gave the man a year 
of comfort by freeing him from the great pain 
and allowing him to eat solid food. 

Case XXXII, aet. 53, was seen on the 12th 
of May, 1904. This patient was a medical 
man and had first noticed a growth the size of 
a small hazelnut on the fraenum of the tongue 
in October, 1903. At about the same date he 
felt an enlarged gland on the right side of the 
neck. In January, 1904, the growth in the 
mouth began to ulcerate, and three weeks later 
there was a severe haemorrhage. There was 
no history of malignant disease in the patient's 
family. 

As operation from the first had been entirely 



CASES OF CARCINOMA 125 

out of the question, the previous treatment 
had consisted in X-rays, radium, injections of 
soap, and of Chian turpentine. He was of 
opinion that none of these remedies affected the 
growth one way or the other, but the injections 
of Chian turpentine were too painful to be con- 
tinued ; indeed, the patient said that on the whole 
the disease was the lesser evil. On examination, 
an ulcerating mass situated in the floor of the 
mouth and extending on to the gums on both 
sides was seen ; there was also a large mass of 
glands on the right side of the neck. The pulse 
was 96, and the general appearance was bad. 
There was not a great deal of pain, but much dis- 
comfort with offensive discharge. To lessen this 
disagreeable odour, the patient was in the habit 
of using a wash of bichloride of mercury. He 
carried about with him a small bottle of a strong 
solution and whenever he had an opportunity 
simply guessed what he thought would be a suf- 
ficient amount of water to add. He was often 
warned that this was not safe and that he ought 
to be more careful, but being a doctor he was 



126 CANCER 

probably not so careful as an ordinary person 
would have been. There was more or less 
bleeding every day. Thirty injections seemed 
to check the disease ; the disagreeably smelling 
discharge was lessened in amount and became 
almost odourless ; the bleeding almost stopped ; 
there was not so much discomfort; and the 
growth inside the mouth had diminished and the 
glands were looser and more defined. The doc- 
tor himself was satisfied and considered that the 
disease was checked. 

The patient went home for the month of Au- 
gust. Symptoms of a very severe attack of 
mercurial poisoning developed, the gums be- 
came soft and spongy, and as the general health 
decreased the malignant disease increased. It 
seemed to be useless to recommence treatment, 
and the patient himself felt that his chance was 
gone. Though he lived on until March, it is 
improbable that the case would have ended in 
complete recovery even without the mercurial 
poisoning. The patient was more hopeful 
than we were, as the injections were the only 



CASES OF CARCINOMA 127 

thing which had touched the disease in the 
slightest degree. The poisoning was undoubt- 
edly due to the reckless use of a too strong solu- 
tion of the mercury. 

Case XXXIII, aet. 71, was seen in March, 1905. 
In September of the previous year he noticed 
that he had some difficulty in swallowing. This 
steadily became worse till he could only get down 
slops. While there is no actual pain, there is 
constant discomfort, and he says that he is 
rapidly getting thin and weak. 

His wife died of cancer, but he knows of no 
history of the disease on his own side. 

The cancer was situated in the larynx, the 
upper part of which was seen to be ulcerated. 

The patient had twenty injections, which made 
him more comfortable certainly, and seemed to 
check the disease somewhat, but there was not 
sufficient improvement to encourage one to 
continue the treatment. This is another ex- 
ample of a case of malignant ulceration. 

Case XXXIV, aet. 60, was first seen on the 
26th of June, 1905. The history of this case 



128 CANCER 

was that two years ago he first noticed that 
his voice was husky, and on consulting a 
specialist a year later cancer of the larynx was 
diagnosed. It was not considered advisable to 
remove the larynx on account of the general con- 
dition and tracheotomy was performed instead. 

This case was an entirely experimental one, 
and it was arranged that fifteen injections 
would be given, and if there were not decided 
improvement by then that the treatment would 
not be persevered with. The almost total 
absence of lymphatics to the larynx made us 
think that there might not be any satisfactory 
result. Although the patient was only sixty 
years of age, he looked much older. He had 
a slow pulse with atheromatous vessels and 
there were no enlarged glands, but he was 
not a good subject for any kind of treatment, 
operative or otherwise. There was no pain 
and there was no family history of cancer. 

At the end of the prescribed course of treat- 
ment neither the local nor the general condition 
had improved to any extent. 



CASES OF CARCINOMA 129 

Case XXXV, act. 49, was seen on the 26th 
of July, 1905. The history was a particularly 
short one, as the patient was positive that the 
first symptom of the disease did not appear 
until nine weeks before his first visit. He said 
that what first drew his attention to anything 
being the matter was finding that he had some 
discomfort when he chewed anything, and after 
a meal there was some pain in the mouth. 
On looking into his mouth he saw a crack 
below his tongue on the right side. About a 
couple of weeks after the first onset it was 
noticed that there was some swelling of the 
neck below the jaw on the right side. As the 
symptoms increased he went to the West 
London Hospital on the 10th of July. He 
was there told that he had cancer and that an 
operation was not advisable as it would require 
to be a very extensive one, that the risk of 
operation would be great, and, as the disease 
was increasing so rapidly, the prospect of 
obtaining a cure extremely doubtful. 

A second opinion was obtained at the Cancer 



i 3 o CANCER 

Hospital. The diagnosis arrived at was much 
the same, viz., a very rapidly growing cancer, 
which by a very extensive and formidable 
operation might possibly be completely re- 
moved. The patient thought that while the 
operation was described as possible, the surgeon 
was not anxious to undertake it. 

The local condition when the patient was 
seen a fortnight after the visit to the Cancer 
Hospital was as follows: there was a large 
mass of glands extending from the symphysis 
menti to the angle of the jaw on the right side, 
adherent to the bone; inside the mouth, there 
was a hard swelling in the floor extending far 
back, and in it and close to the bone an ulcera- 
tion nearly an inch in depth and almost two 
inches in length. The least that would have 
been required to be done if an operation had 
been attempted would have been removal of 
half the tongue, half the lower jaw, half the 
floor of the mouth, the whole of the glands in 
the anterior triangle and the parotid on the 
right side. It seems to us doubtful if any 



CASES OF CARCINOMA 131 

surgeon with any extensive experience of such 
cases would submit himself to any such opera- 
tion. The patient could eat no solid food and 
had to subsist entirely on fluids. He was losing 
weight and the pulse was 96. 

On account of the extreme rapidity of the 
growth, a very unfavourable prognosis was given. 
It seemed impossible to believe that such an 
extensive amount of disease could have grown 
in the time stated, nine weeks, but the patient, 
an intelligent man, and his family were certain 
of their dates. Suffering was so great and so 
little encouragement had been given to induce 
him to undergo the operation that he agreed 
to have the injections to obtain relief. Very 
large doses were given and the pain was dis- 
tinctly better after the third, and he could eat 
solid food with comfort after he had had six. 
By this time the pain had entirely disap- 
peared. 

On the 24th of September the forty-first 
injection w T as given. The patient was more 
than holding his own; he had gained weight, 



i 3 2 CANCER 

the pulse was 84, the glands were smaller, and 
the ulceration had begun to heal. Up to this 
time about five injections had been given per 
week. The treatment was discontinued for 
a fortnight, but in this short time he went 
back in so far as the local condition was con- 
cerned. Improvement followed recommence- 
ment of the injections. 

On the 23d of December injections of trypsin 
were unfortunately begun. At first this seemed 
to do good as the glands diminished in size 
more quickly, though the condition of the 
mouth remained stationary. On the 1st of 
January, 1906, it was noted that the glands, 
though they were fully smaller by a half than 
they had been originally, were becoming cystic. 
Increase in size was then rapid and four days 
later 5ii of bloody serum were removed 
by aspiration. The aspirator had to be fre- 
quently used until the 27th of the month, when 
the skin broke, and a large amount of brain- 
like matter came away. From now onward 
until the date of his death in June, progress 



CASES OF CARCINOMA 133 

was steadily downhill, and more and more of 
the mouth and neck sloughed away, until be- 
fore his death there was an opening almost 
large enough to admit one's hand. Part of 
the right half of the lower jaw necrosed. There 
were several attacks of haemorrhage, and the 
patient suffered very much for six weeks before 
he died. It would be interesting if we could 
know what would have happened if the trypsin 
had not been used. It seems to us that the 
arsenical injections would not have cured him, 
as the case was a most virulent one as shown by 
the great rapidity of growth at first, and the 
quickness with which the disease asserted itself 
after the forty-first injection, when they were 
discontinued for two weeks. Until the trypsin 
was used the disease was held in check, and a 
little over, for five months. In such an acute 
case it looks as if there had been some specific 
action on the disease not simply temporary 
improvement, and it is probable that the tryp- 
sin was responsible for the rapid destruction 
of tissue, different altogether to any we have 



i 3 4 CANCER 

ever seen in cases of cancer except when this 
drug was being used. 

Case XXXVI, aet. 77, but looking decidedly 
younger, was seen in April, 1907. 

His story was that two years before he had 
a feeling as if there was a piece of seaweed in 
his mouth. This sensation increased, and 
on looking into the mouth a large mass was 
seen growing from the root of the tongue, 
adherent to the floor of the mouth and lower 
jaw, and extending across the mouth. The 
tongue had little mobility and could not be put 
out at all. He could swallow fairly well, but 
with discomfort. An ulcer on the nasal septum 
was also to be seen. The patient had had 
syphilis many years ago, but no enlarged glands 
could be felt. The pulse was 96 and he had 
not lost much flesh. 

After twelve injections, the treatment being 
carried out by his own doctor, the swelling 
was rather smaller especially in front, he could 
swallow better, and the tongue was more 
movable. The pulse had come down to 78. 



CASES OF CARCINOMA 135 

Unfortunately the treatment had a most ex- 
traordinary effect on his bowels, as on injection 
days, after the bowels were moved, he was 
prostrated with pain for several hours. 

When another twelve injections had been 
given, they were temporarily discontinued, and 
mercury was tried instead. The result was 
not satisfactory, as the patient quickly became 
salivated. 

At the end of August the patient said he 
felt rather better and was anxious to continue, 
though the growth had begun to break down. 
The injections which were at first given twice 
a week had to be reduced to once on account 
of the bowel pain. In the middle of October, 
after a fortnight's stoppage of treatment, the 
growth was extending toward the cheek. 



CASES OF SARCOMA 

Case XXXVII, aet. 40, was seen first on the 
2d of June, 1903. The case is a most in- 
structive one and presented several points of 
interest. The previous history was as follows: 
the woman had always been very poor, she 
had eight children, and there had been several 
miscarriages. In regard to her general health 
she said that she had never ailed anything. 
It was as well, considering where she lived and 
what she and her family had to live on. In 
August of the previous year her attention 
had been drawn to a lump in her right breast, 
and on attending at St. Mary's Hospital, she 
was admitted as an in-patient, and the growth, 
not the breast, removed. The pathological 
report was "no sign of malignant disease — 
it was a specimen of interstitial mastitis," 
but the gentleman who kindly communicated 

136 



CASES OF SARCOMA 137 

with us added that he did not know how much 
of the growth had been examined. There 
seems, however, to have been some doubt about 
the exact nature of the disease, as the patient 
was warned that she must come back imme- 
diately if she noticed any return. Almost at 
once after leaving hospital the patient became 
pregnant and she thought that the growth 
returned very soon after this happened. She 
was a stupid woman, and it did not seem to 
occur to her that she should do what she had 
been told, and it was only on the persuasion of 
the midwife who attended her in her confine- 
ment, in the beginning of May, that she was 
induced to go back to the hospital. She went 
on the 1st of June, and the surgeon was evidently 
much annoyed that she had not done what she 
had been told and come earlier, as he said that 
it was then too late and that she could only 
expect to live a very short time. 

On the 2d of June, i.e. ten months after the 
operation, a large cystic mass was found in- 
volving the pectoralis major, somewhere about 



138 CANCER 

the size of a couple of billiard balls. There 
was a second flattened-out and apparently 
solid growth over the upper part of the ster- 
num, and in addition there were several small 
cystic nodules. 

To apply ordinary surgical principles to such 
a case meant, in our opinion, to do nothing, 
for it would have been impossible to remove the 
mass over the sternum, as it was adherent to the 
bone. The prognosis was unfavourable, as the 
patient was losing ground and beginning to 
feel weak. At the best, a very few weeks, 
possibly eight or ten, would have been the 
utmost time one could expect her to live. 

It was a difficult question to know what one 
ought to do. Here we had a poor woman 
whose life was a valuable one to her husband 
and her children, whose work seemed to be 
done, and who had a very short time to live. 
Should we try an experiment or should we 
simply let her die? In such a case the diffi- 
culty is to determine whether there is any 
likelihood of the experiment doing the patient 



CASES OF SARCOMA 139 

good or whether we would only gain informa- 
tion. 

It was evident that the first thing to do 
would be to remove the cystic part of the disease 
to prevent it bursting through the skin. To 
deliberately remove part of such a growth is 
such foolishly bad surgery, under ordinary 
circumstances, that we advised the poor woman 
to try another hospital and come again if noth- 
ing were done, hoping in this way to get rid 
of her. All the surgeons at the New Hospital 
and one from Charing Cross saw the case, as 
it was considered an interesting one and one 
deserving of study, and all were unanimously 
agreed that the patient could only live a few 
weeks, and that nothing could be done. She 
then came back to us and we had to tell her 
that we would do what we could. The cystic 
portion had so thinned the skin that rupture 
was imminent and it was evident that much 
misery would be saved if that part could be 
removed and the wound healed. It therefore 
seemed to be justifiable to perform a partial 



140 CANCER 

operation and then see what the injections 
would do. To have attempted to remove the 
part over the sternum would of necessity have 
left an open wound. 

On the 17th of June the cystic mass along 
with part of the pectoral muscle was removed. 
Microscopic examination pronounced the dis- 
ease to be a small, round-celled sarcoma. 

The wound healed by first intention in spite 
of the surroundings, which were not of the 
sweetest. 

We rather wondered what a student accus- 
tomed to the cleanliness of the hospitals would 
have thought, for the street was dirty, the house 
was dirty, and the patient was only cleaned 
up for the occasion ! Injections of 5 c.c. were 
begun seven days later and were at first given 
daily. By the end of August she was in good 
health, able to look after the children, and do 
her work and washing. Forty-eight injections 
had been given in just under ten weeks. Several 
small cysts were projecting through the scar, 
and there was one granulating mass the size 



CASES OF SARCOMA 141 

of a threepenny bit near the upper part of it. 
The growth over the sternum was not so large, 
but the bone itself had become much thickened. 
Encouraged by the good general condition, 
she being apparently a well woman instead of 
being on her death-bed, a somewhat extensive 
operation was performed on the 7th of Sep- 
tember, everything abnormal being removed 
as widely as possible. The growth over the 
sternum turned out to be a flattened-out cyst 
filled with papillomatous-like material and was 
incorporated with the periosteum, which had 
to be scraped off the bone with a sharp spoon. 
Again the specimen was found to be a small, 
round-celled sarcoma. The injections were 
stopped for ten days only and were then con- 
tinued daily until the 16th of October. The 
patient was able to be up a week after the 
operation, though the part over the sternum 
had to be left open and made to heal by granu- 
lation. At the end of September a small cyst 
appeared in the upper angle of the wound and 
soon after another at the other end. After 



142 CANCER 

an interval of twelve days the injections were 
begun again on the 28th of October and were 
continued until the beginning of April. In 
the whole ten months of treatment between 
one hundred and fifty and two hundred injec- 
tions were given. 

In the beginning of December the cysts 
suddenly started into activity, and this increase 
was found to be coincident with the patient 
becoming pregnant, as was shown by a mis- 
carriage at about six weeks in the middle of 
January. There w T as temporary improvement 
after the miscarriage, but soon, though the 
general health kept good, the mass over the 
sternum began to grow again. 

On the 26th of February a third operation 
was performed; but the wound, which again 
could not be brought together, never healed, 
and by the middle of March there was a fun- 
gating mass projecting from it. This was kept 
in check by repeated applications of caustic 
potash. 

In the beginning of June there was some 



CASES OF SARCOMA 143 

difficulty in breathing, there was oedema of the 
lungs and also of the face and arms, with great 
enlargement of the superficial veins which be- 
came varicose, showing that there was some 
internal deposit. Nine additional injections did 
good, the last being given on the 4th of July. 

By the end of July there was a return of 
the difficulty in breathing, and it was ascer- 
tained that the woman was three months 
advanced in pregnancy. She died on the 
24th of August, having taken to her bed only 
one week before. About the middle of the 
month some fluid appeared in the peritoneal 
cavity. 

Pregnancy seemed to have a disastrous 
influence on this case. As soon as the woman 
became pregnant, the disease increased with 
great rapidity. The quick return after the 
first operation in hospital, the sudden increase 
in December, and the evidence of internal 
deposit in June, all were evidently connected 
with this condition. Until within a few days 
of her death there was never any pain. The 



144 CANCER 

patient did not know of any relations who 
had died of cancer; but as she was a most 
ignorant woman, could not read or write, her 
evidence is not of much value on this point. 
Fortunately on almost every other matter we 
did not have to depend on her statements. 

It seems certain that this patient gained a 
year of good health by means of the injections, 
assisted by the operations. Neither would 
have been sufficient, and it is not likely that 
all the surgeons who saw the case were mis- 
taken, and that under ordinary circumstances 
the patient would have lived for nearly fifteen 
months. We say lived, not merely existed, 
because for over a year she was as if nothing 
were the matter with her. Undoubtedly she 
was a strong woman naturally, and this helped 
to make the operations a simple matter for her ; 
but the fact remains that in the beginning of 
June, 1903, it was unanimously agreed that 
she would not live three months at the outside, 
and that twelve months later she was still well 
enough to look after a family of eight children. 



CASES OF SARCOMA 145 

Case XXXVIII, aet. 53, was seen in August, 
1903, having first noticed the swelling, to be 
described, in June, two months before. He 
looked an old, broken-down man, and was really 
hardly able to come to see us. The pulse was 
small and 104. 

In July he was admitted into Charing Cross 
Hospital. While there he was anaesthetised and 
a long incision made over the tumour. No 
part of the growth was removed. 

In August there was a flat mass apparently 
between one and two inches in thickness, quad- 
rilateral in shape, measuring between five and 
six inches across, extending from the right of 
the middle line well into the left iliac region. 
The growth appeared to be situated in the 
deeper layers of the abdominal wall. 

Now we would probably not treat such a case, 
though it is still difficult to resist trying to help, 
while at the same time one may be gaining infor- 
mation. The reasons why the case ought not 
to have been touched were the rapidity of the 
growth, and as the man was intelligent his 



146 CANCER 

account could probably be depended on, and the 
very great effect the disease had had on his gen- 
eral health. In two months he had passed from 
being in good health to being a decrepit old man. 

Injections, of the original weak strength, were 
given three times a week. They acted mar- 
vellously, and by the end of September the man 
felt quite well. There was as quick improve- 
ment as there had been rapid deterioration. 
The pulse was good at 80, and he was putting 
on flesh. The growth, however, did not lessen 
much in size. 

On the 9th of October the scar opened and pus 
was discharged, and on the 13th of November 
there was no doubt that a communication with 
the bowel had been formed. In spite of the 
trouble and annoyance given by the fistula, the 
patient's general health kept good until the end 
of January. After that time he steadily lost 
ground and died on the 16th of April. 

The growth was evidently a rapidly growing 
sarcoma, though there was no examination after 
death to definitely settle this point. The possi- 



CASES OF SARCOMA 147 

bility of its being a gumma was carefully gone 
into, but no evidence was found to justify such 
a diagnosis. 

The improvement in the general health was 
most marked. In two months from the time 
that the growth was first noticed the man had 
lost ground tremendously, and the treatment 
within half that time had made him apparently 
well, in spite of the disease. 

Case XXXIX, aet. 42, single, was first seen in 
April, 1904, and gave the following history: so 
far as she knew none of her relations had died 
of malignant disease and though she herself 
was not robust, her general health had always 
been good. In the beginning of 1902 a growth 
described as being the size of a large orange 
was removed from the left breast. This had 
been noticed for six weeks. It had not given 
rise to much pain and what there was, was prob- 
ably due to the weight. The operator said that 
the growth was a healthy one and that there 
would be no return. However, a second tumour 
had to be removed within two years, in January, 



i 4 8 CANCER 

1904. This growth was also said to be benign. 
In April of the same year we were consulted 
about a third tumour the size of a large walnut 
and advised its removal along with all that 
remained of the breast. This was done on the 
15th of April, but not quite satisfactorily, as 
there was a large amount of scar tissue over 
the sternum. 

The following is the microscopic report: " Fi- 
brosarcoma. It is arranged in bundles of 
spindle cells with much fibrous change in the 
material. Hence the degree of malignancy is 
low." 

Thirty injections were given as soon as the 
patient was able to be out of doors. Fourteen 
months after this third operation, a fourth had 
to be performed, as a small nodule had appeared 
over the sternal end of the scar. This nodule 
was removed freely and the microscopic exami- 
nation was most satisfactory as no trace of ma- 
lignancy was to be found. Both examinations 
were made at the same agency, and attention 
was specially drawn to the first report. The 



CASES OF SARCOMA 149 

patient did not know if either of the first two 
growths had been examined microscopically, 
but thought not, so to this extent the case is not 
complete. It is, however, interesting to note 
that while the third growth was malignant though 
not very acutely so, in the fourth the tumour 
consisted of fibrous tissue alone and was 
a simple, non-malignant growth. This, com- 
bined with the fact that there has been no return 
for over two years, or no return of malignant 
disease for over three and a half years, seems as 
far as one case goes to point to the treatment be- 
ing able to lessen the tendency to the formation 
of malignant disease. One must, however, be 
careful not to lay too much stress on a single case. 
Case XL, aet. 36, married, was seen on the 20th 
of May, 1904. She did not know much about 
her relations, but so far as she was aware there 
was no cancer in the family. Since the birth of 
her first child, ten years before, there had been 
pain and discomfort in the left breast. In 
December, 1903, the breast began to swell and 
became much more painful. She attended as 



ISO CANCER 

an out-patient at one of the hospitals, and after 
three months of treatment by local applications 
and medicines, a transverse incision was made 
from the nipple to the edge of the breast. 

When first seen in May the breast was found 
to be much swollen and there was a partially 
healed w r ound, discharging pus. At first the 
breast was in such a tender condition that it 
could not be satisfactorily examined, but after 
a few weeks' rest and proper care much of the 
tenderness was relieved, and on careful examina- 
tion a hard nodule the size of a hazelnut was 
felt. No mention of this had been made at the 
hospital, so we have no guide as to how long it 
had been growing. It is quite likely that it 
may have been present when the patient was 
attending the hospital, as careful examination 
was required to find it, and to any one conver- 
sant with out-patient rooms and the numbers re- 
quiring to be seen in a limited time it can easily 
be supposed that proper attention was not given. 

The patient was steadily losing flesh. 

The breast was removed on the 25th of June. 



CASES OF SARCOMA 151 

The hard nodule was sent to be examined 
microscopically and was pronounced to be a 
large, spindle-celled sarcoma. Thirty injections 
were given commencing on the nth of July, and 
for three and a half years there has not been 
any return. 

Too much stress must not be laid on this case, 
for if we are to reason from a single one we would 
have to condemn all out-patient rooms, which 
would be as absurd as to claim a discovery 
based on the evidence of a single case. 

Case XLI, aet. 63, had always enjoyed good 
health until she was over fifty years of age, when 
she began to suffer from symptoms due to gall- 
stones. At the age of 57 the stones had been suc- 
cessfully removed, but in the summer of 1904 
she noticed that there was some hardness in the 
scar. She was a very reticent woman about her 
health, though her husband was a doctor, and at 
first, not connecting in any way this hardness 
with some feeling of weakness, did not say any- 
thing about it. There was no pain at this time. 
So far as we could learn, none of her relations 



152 CANCER 

had died of any form of malignant disease. 
The growth was entirely removed on the 5th of 
August, 1904, but before the end of September 
there was extensive recurrence of the disease in 
both groins, and in the right axilla. A second 
operation on the three places was performed, 
and a third was considered advisable for recur- 
rence in the left groin three months after the first. 
Although this operation was a very extensive 
one, the disease could not be entirely removed. 
Before the wound had healed, nodules had ap- 
peared on the left labium, thigh, and abdomen 
almost as high as the umbilicus. The patient 
was confined to bed, and the surgeon who had 
performed the operations gave her not more 
than three months to live, and was afraid that 
the death would be a very painful one. 

When the injections were begun on the 20th 
of November the condition was deplorable; 
the thigh, labium, and lower left half of the ab- 
domen were as red as a piece of uncooked meat, 
and there were numbers of nodules in the skin 
varying in size from a split pea to a bean. The 



CASES OF SAX COMA 153 

patient had lost weight, was flabby and weak, 
and was unable to be out of bed. The pulse 
was 112. 

The treatment was specially slow in getting 
any hold on the disease, which continued to 
spread, and it was only because the husband 
knew that the injections were the last chance that 
he could be encouraged to persevere. After 
about the tenth or twelfth injection, the progress 
of the disease seemed to be checked and the 
general condition had begun to decidedly im- 
prove. The surgeon who had not seen the case 
meanwhile was asked what he thought of her 
going to Tunbridge Wells for Christmas. His 
answer showed that he considered the case not 
only hopeless but likely to prove fatal quickly, 
as he said, "If you take her, you will never 
bring her home again." The patient was anx- 
ious to go and we advised the change, having 
confidence that the improvement once begun 
would continue. 

On the 9th of February the thirtieth injection 
The patient was then in her usual 



154 CANCER 

state of health, able to go out in the evening, 
do her own shopping, etc., and had gained close 
on two stone in weight. 

In the beginning of April the right arm began 
to swell and some hardness was found in the 
axilla. A second course of thirty injections was 
begun and was completed on the 7th of August. 
No trace of disease could then be found any- 
where. The patient went abroad until the end 
of October and came home apparently quite 
well. Toward the end of the month she com- 
plained of pain in the left groin and on exami- 
nation the leg and thigh were found to be 
swollen. On deep pressure a mass could be 
felt in the lower part of the abdomen. The 
injections were resumed, but without any bene- 
ficial effect. The patient became weaker, the 
heart dilating and causing oedema of the lungs, 
and she died on the 13th of December. She 
suffered a good deal during the last month from 
swelling of the legs and the chest trouble, but 
fortunately the disease did not appear again on 
the surface, and she was spared that misery. 



CASES OF SARCOMA 155 

The question arises in this case of how much 
surgery ought to try to do. Was the second 
operation justifiable on sound surgical prin- 
ciples? Secondary growths appearing in three 
different parts of the body a few weeks after the 
first operation point conclusively, one would 
think, to a condition of general infection, and 
that the disease in no way could be considered a 
local one. It is therefore difficult to understand 
on what principle the operations were performed. 
The third operation three months after the 
first seems to have been lacking in any justifi- 
cation whatsoever. Not only correct surgical 
principles but even ordinary common sense seem 
to have been ignored. On the other hand, the 
injections, while they were not successful in the 
end, gave the patient nine months of good health 
instead of the three months of acute suffering 
which appeared to be certain after the last opera- 
tion, and a comparatively easy death. 

The pathological report of the growth removed 
at the first operation stated that it was a round- 
celled sarcoma. 



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Climatology. 

THE MACMILLAN COMPANY 

PUBIISHEKS, 64-66 FIFTH AVENUE, NEW YOEK 



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